Running Head: BIOPSYCHOSOCIAL PAPER 1 Biopsychosocial Paper Michelle Dearduff Kent State University, Stark Campus Running Head: BIOPSYCHOSOCIAL PAPER 2 Introduction M.S. is a forty six year old Caucasian male, admitted to Heartland Behavioral Health (HBH) in 1994 for assault found not guilty by reason of insanity. M.S. was released on Conditional Release. M.S. returned to HBH on February 26, 1996 due to violations of the Conditional Release. M.S. was readmitted after threats were made towards family, and refused to comply with antipsychotic medications. The patient’s first psychiatric admission was in 1986 at Medical Mercy Center. M.S. has four hospitalizations at Mercy and eight at HBH since 1987, with the frequency attributed to noncompliance with medications. In 1987 M.S. attempted suicide by shooting himself in the mouth with a hand gun. The bullet lodged in posterior pharynx and could not be removed. M.S. has had alcohol abuse and cannabis abuse, which is in full remission controlled by environment. M.S. has not required seclusions or restraints. M.S. has level five movement privileges. The patient’s current diagnosis includes Axis I schizoaffective disorder, bipolar type, Axis II personality disorder, Axis III hyperlipidemia, hypercholesterolemia, Axis VI no information, Axis IV Global Assessment of Functioning is 65. M.S. medical history would include gastroesophageal reflux disorder, chronic constipation, obesity, hyperlipidemia, and hypertension. Diagnostic tests done on M.S. were a Hemogram on 10/7/09, Therapeutic drug monitoring, Echocardiogram report 5/15/07, and a Nuclear stress test. This writer has met and talked with M.S. on three occasions. Mental Status Examination/ Mental Health Assessment Running Head: BIOPSYCHOSOCIAL PAPER 3 The client’s appearance was casually groomed and dressed in a button down shirt and jeans. M.S. was cleaned shaved, and hair was brushed. M.S. had an open and cooperative behavior towards this writer. The client’s psychomotor activity is noted to be normal without any increase or decrease in activity. M.S. had normal posture, facial expression was also normal, with direct continuous eye contact throughout conversation. M.S. was responsive to this writer. The client’s mood was euthymic and affect was full and congruent. M.S. was oriented to person, place, and time. Recent and remote memory were intact, three out three objects were recalled within five minutes. M.S. had a hard time concentrating on this writer’s main questions. M.S. lacks insight towards mental illness and has limited understanding of the conditional release process. Patient states “I do not need to be in here, I am not crazy and I was not serious when I said I would hurt my family.” M.S. has good judgment, when asked what M.S. would do if there was a letter outside of a mailbox, Patient states “I would walk away from the letter.” This client’s speech is without any difficulty including inflections or speech impediments. This client’s though content does show grandiose fixed delusions. M.S. states “I have rewritten Einstein’s Theory of Relativity, and I am almost finished with my book.” M.S. also states “I have a fixation on numbers and am really good with math, and that’s why people think I am crazy.” M.S. currently had no thoughts of suicide or homicide. When asked about the threats against family and him, Patient states “I was not being serious, and I was getting tired of holding the gun when I accidently shot myself.” M.S. shows no derailment of thought and no flight of ideas noted. M.S. does have illogical thought process due the fixation on Einstein’s theory. M.S. denied current experience with visual or auditory hallucinations. M.S. denies any presence of pain. When asked about thoughts of a suicidal plan, patient denies any plan or thoughts to harm self. M.S. does have a history of attempted suicide. The client does have a bullet lodged in pharynx due to a failed suicide attempt. When patient does not comply Running Head: BIOPSYCHOSOCIAL PAPER 4 with medications, risk to self increases. The client also has a history of threatening family members with a gun and patient admits to being violent with family members. M.S. currently denies any homicidal ideation towards family or others. Substance Use/Abuse M.S. has an extensive history of substance abuse and other mood altering substances. According to the patient’s chart there has been alcohol and marijuana abuse. When asked about using substances, patient does not admit to any use of substances. M.S. does attend a dual recovery program. With the treatment teams advice M.S. has to attend at least one Alcoholics Anonymous, Integrated Dual Disorder Treatment (IDDT), or Substance Abuse and Mental Illness program (SAMI) a month. M.S. does not have any compulsive behaviors such as gambling or sexual addictions. Social Functioning This client does not socialize very often with other patients due to his delusions. Client states “they all think I am crazy, because I am good with numbers, and I like to talk about the Big Bang theory, so I just don’t talk much to them.” M.S. maintains a good relationship with the case manager. M.S. primarily worked in restaurants as a dish washer prior to admission to HBH. M.S. currently works three hours a week for Heartland’s patient newsletter. M.S. identifies with Roman Catholic faith. M.S. does not attend church services on HBH grounds. There are no cultural/spiritual activities that this patient is unwilling to participate in due to his culture/spiritual background. M.S. has never been married and has no children. Running Head: BIOPSYCHOSOCIAL PAPER 5 Client/family appraisal of health and illness M.S. has a good family support system. The client’s mother and brother are both actively involved in M.S.’s treatment, and care by meeting with the treatment team. They visit M.S. on occasion and the brother is allowed to take M.S. to group meetings that are outside of HBH. When asked about M.S.’s mother and brother visiting patient states, “I have not seen them in a few months, and I don’t want to talk about that.” Heartland Behavioral Health reinstated M.S. into the work readiness program. If M.S. has good work skills, HBH will pay M.S. minimum wage. M.S. does utilize the HBH business office by depositing funds for personal spending on grounds and saving money for a group home. This writer asked M.S. about these funds, and patient denies having any money. According to the client’s chart, M.S. has a great work history and able to complete job duties in an excellent manner. Client states that, “I don’t have any money saved up for a group home and that’s why I can’t leave here.” M.S. claims to be motivated for treatment and care. This writer asked M.S. about specific goals that the client has in order to leave HBH. M.S. has no response to the question and instead continues with the Einstein theories. This writer asked the client about current stressors at HBH, the client states “I do get stressed when people think I am just crazy, and don’t listen to what I have to say, I am just good with math.” “The time in here also makes me stressed, because it goes by slow, so I just stay in my room and write my book.” M.S. responds well to medications and treatment. M.S. understands that medication is necessary, but does not like attending groups. M.S. states “The groups are pointless and they don’t help me because I don’t have the problems they talk about.” Running Head: BIOPSYCHOSOCIAL PAPER 6 Client’s Strengths M.S. has a few strengths that will assist with maximizing one’s overall quality of life. A current asset that M.S. has is that there is a response to treatment. M.S. responds well to medications and treatment such as the groups. Overall M.S. has a supportive family that continues to be involved with treatment. M.S. is at level five privileges. M.S. is allowed to leave HBH with brother to participate in group treatment. This client currently is employed at HBH and has an excellent work history. According to this clients chart, there is money saved up for a group home. M.S. also has a creative side and loves to write. M.S. has the skills to be able to live in a group home, and with the support of family will be able to maintain a medication/treatment regimen. Client’s Needs This writer concluded that M.S. has three major needs based on this assessment. One major need is financial resources that will keep M.S. in a group home and out of HBH. The client states that there is no money saved up from the newsletter job at HBH. Patient states “I spent all that money I had saved up on paper and ink for my book.” The other need that is a priority is substance and alcohol abuse. M.S. has a history of substance abuse, and has responded well to groups. It is important for M.S. to continue to attend this treatment throughout life in order to prevent an exacerbation of mental illness. The last need would be medication compliance. M.S. has a supportive family to help with ensuring compliance with medications. Educating the family on signs and symptoms of nonadherence , to prevent readmission to HBH. Running Head: BIOPSYCHOSOCIAL PAPER 7 Client’s Developmental level using Erickson According to Erickson, M.S. should be in the generativity versus stagnation stage. The main components in this stage are to ask a question, “Will I produce something of real value?” During middle age the primary developmental task is one of contributing to society and helping to guide future generations. A person makes a contribution during this period a sense of generativity results, such as raising a family. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation. M.S. is not currently functioning in this stage of generativity versus stagnation. M.S. does fall into this stage of development. Even though M.S. is currently unable to live outside of HBH, patient states “I would like to have a family someday.” M.S. does have the ability to achieve mature, civic, and social responsibility. M.S. also uses leisure time creatively by writing for the newsletter at HBH. M.S. appreciates family support and states “I love my family and miss them.” This writer would conclude that M.S. is at the generativity versus stagnation stage of Erickson’s developmental stages. Running Head: BIOPSYCHOSOCIAL PAPER 8 Medication Use in Patient Side Effects Nursing Implications Risperdal Consta Schizophrenia Neuroleptic Monitor for development of NMS (fever, respiratory 50mg IM every two Malignant Syndrome distress, tachycardia, seizures, diaphoresis, hypertension, weeks (NMS), dizziness, pallor, tiredness). Notify physician or other health care extrapyramidal professional immediately if these symptoms occur. Monitor reactions, headache, patient’s mental status (delusions, hallucinations, and insomnia, behavior) before and periodically during therapy. Monitor constipation, weight blood pressure (sitting, standing, lying down) and pulse gain, decreased libido before and frequently during initial dose titration. Monitor patient for onset of extrapyramidal side effects (akathisia- restlessness; dystonia-muscle spasms and twisting motions; or pseudoparkinsonism-mask-like face, rigidity, tremors, drooling, shuffling gait, dysphagia). Report these symptoms; reduction of dose or discontinuation may be necessary. Monitor for tardive dyskinesia. Report immediately; may be irreversible. Depakote 500mg Manic episodes Hepatotoxicity, Assess mood, ideation, and behavior frequently. Monitor every morning associated with nausea, rashes, hepatic function and serum ammonia concentration prior to bipolar disorder pancreatitis, and periodically during therapy. Monitor CBC, platelet confusion, dizziness, count, and bleeding time prior to and periodically during sedation. therapy. Zyprexa 20mg every Schizophrenia NMS, seizures, Monitor for development of NMS, Monitor for tartive evening agitation, restlessness, dyskinesia, Monitor blood pressure, Monitor blood glucose orthostatic in patients with diabetes, and prior to and periodically hypotension, during therapy in patients with risk factors for diabetes. tachycardia, weight gain, hyperglycemia, tartive dyskinesia. Benztropine Extrapyramidal Constipation, dry Assess parkinsonian and extrapyramidal symptoms before (Cogentin) 1mg twice effects due to mouth, dry eyes. and throughout therapy. Assess bowel function daily. daily antipsychotic Patients with mental illness are at risk of developing medications exaggerated symptoms of their disorder during early Running Head: BIOPSYCHOSOCIAL PAPER 9 therapy with benztroprine. Withhold drug and notify physician or other health care professional if significant behavioral changes occur. Running Head: BIOPSYCHOSOCIAL PAPER 10 Priority Nursing Diagnosis Short and Long-Term Goals Nursing Interventions/Actions Rational Noncompliance related to an Short term goal: M.S. will 1. Nurse will assess how 1. Age, religion, cultural active decision of an individual negotiate acceptable changes in the patient’s disorder beliefs, and to fully or partially nonadhere the treatment plan that he is and subsequent expectations of others to an agreed-on willing to follow by 11/23/09 treatments/medication all impact on our value medication/treatment regimen, impact upon patient’s system and factor into As evidence by M.S. returning (and family’s) lifestyle. how we make decisions. to Heartland Behavioral Health Long term goal: M.S. will state (Varcarolis, 2006). RN: (Varcarolis, 2006). after shortly being released on correct information about his “Tell me how going to 2. Client (family) Conditional Release which condition, benefits of treatment, groups and taking your misperceptions about consisted of medication risks of treatment, and medications have disease/disorder or compliance. Patient states “I treatment options each time helped you receive level treatments result in did not take my meds, and changes are made to their 5 privileges?” M.S. faculty decision that’s why I did bad things.” treatment plan by 12/9/2009 “When I go to groups making. (Varcarolis, and take my 2006). medications, I am able 3. People need to know to work, and type my that, in most instances, book on my computer, medications cannot cure and I can leave HBH them, but they can help with my bother.” RN: stabilize their symptoms “So when you follow with time. Ultimately, your treatment plan, the final choice is with you are able to live a the client. Our job is to better lifestyle, and provide information and learn ways to live effective treatment outside of HBH.” M.S. options that best suit the “Yes, I enjoy being able client’s lifestyle. to leave HBH with my (Varcarolis, 2006). brother for groups.” 4. Nonadherence is often a 2. Nurse will explore with symptom of an patient their feelings underlying problem. about the That problem must be Running Head: BIOPSYCHOSOCIAL PAPER 11 illness/disorder and the identified. (Varcarolis, need for ongoing 2006). treatment. (Varcarolis, 5. The more complicated a 2006). RN: “Do you treatment plan, the more understand that taking likely is nonadherence. your medications will The easier the regimen help you in leaving is to follow, the greater HBH?” M.S. “Yes, I the likelihood of know I need to take my compliance. meds, but I don’t think I (Varcarolis, 2006). am crazy, I am just good with numbers.” RN: “ In order to live a healthy life outside of HBH, it will be important for you to continue taking your medications and going to groups.” 3. Nurse will ask patient to share his rationale for nonadherence to medical/psychosocial regimen.(Varcarolis, 2006) RN: “I read in your chart that you stopped taking your medications and going to groups, before you were readmitted to HBH.” M.S. “I didn’t think I needed to take them then, I was feeling Running Head: BIOPSYCHOSOCIAL PAPER 12 fine.” RN: “What made you think that you didn’t need to take your medications?” M.S. “I was feeling a lot better, and I didn’t think the groups were helping so I told my case manager that she needs to stay out of my business.” RN: “Maybe taking your medications was what made you feel better?” M.S. “Ya, I know I need to take them.” 4. Nurse will review the areas in the treatment regimen that interfere with adherence. (economic, transportation, knowledge barrier, lack of family involvement) (Varcarolis, 2006). RN:”When you were released in 1994, what made you decide not to go to groups?” M.S. “I didn’t think they were helping me.” RN: “Who would take you to the meetings?” M.S. Running Head: BIOPSYCHOSOCIAL PAPER 13 “My case manager, or my sister, that is before I got into an argument with her.” RN: “Does your family visit and are they involved in your treatment?” M.S. “Yes, they visit but haven’t been here in awhile, and my brother usually takes me to my groups outside of HBH, but hasn’t since he had a heart attack.” 5. Nurse will reduce the complexity of the treatment plan (prioritize; facilitate schedules, fit to clients lifestyle.) (Varcarolis, 2006). RN: “Have you thought about your goals for leaving HBH?” M.S. “I’m not sure what I need to do to leave, but I don’t have any money to go to a group home, so I don’t think I am going to get out of here.” RN: “I know you work for the newsletter here at HBH, have you saved Running Head: BIOPSYCHOSOCIAL PAPER 14 up money?” M.S. “I do work, but haven’t saved money.” RN: “Have you attended any groups that discuss ways to save money?” M.S. “No, I haven’t been to groups in awhile.” RN: “Well, it is important for you to find out when they are held and attend them, they can be useful.” Disturbed Thought Processes Short Term Goal: M.S. will talk 1. Nurse will review to 1. Important clues to Related to about concrete happenings in attempt to understand underlying fears and Biochemical/neurologic the environment without the significance of these issues can be found in imbalances, As Evidence By talking about delusions for five beliefs to the client at the client’s seemingly M.S. Grandiose delusion that minutes by 11/23/09 the time of their illogical fantasies. he has rewritten Einstein’s presentation. (Varcarolis, 2006). Relativity Theory. Long Term Goal: M.S. will (Varcarolis, 2006). RN: 2. Identifying the client’s demonstrate two effective “You stated that you experience allows the coping skills that minimize like to write.” M.S. nurse to understand the delusional thoughts by 12/9/09 “Yes, I am writing a client’s feelings. When book about the Big people believe that they Bang Theory and time are understood, anxiety travel.” RN: “Do you might lessen. write for the HBH (Varcarolis, 2006). newsletter?” M.S. “Yes 3. Arguing will only I do, I have an eye in increase client’s my head that is like the defensive position, dollar bill and I can see thereby reinforcing into the future.” RN: false beliefs. This will “What do you write for result in the client Running Head: BIOPSYCHOSOCIAL PAPER 15 the HBH newsletter?” feeling even more M.S. “I don’t write isolated and much for them misunderstood. anymore, but I do write (Varcarolis, 2006). a lot in my room, I am 4. When thinking is 99.9% done with my focused on reality-based book, and hopefully I activities, the client is can make money off of free of delusional that.” thinking during that 2. The nurse will be aware time. Helps focus that client’s delusions attention externally. represent the way that (Varcarolis, 2006). he experiences reality. 5. The implication for (Varcarolis, 2006) RN: therapeutic intervention “Do you have friends with schizophrenics, here at HBH that you then, is that there is a can talk to?” M.S. “Not real need for a system really, most of them just that will provide the think I am crazy, but I patient with a more am just really good with effective means of numbers, they don’t appropriately coping understand me.” with anxiety and stress. 3. Nurse will not argue Schizophrenics with the client’s beliefs experience more or try to correct false subjective stress in daily beliefs using facts. life than normal and (Varcarolis, 2006) RN: find periods of “Tell me about your increased environmental incident with the hand stress difficult to gun.” M.S. “I didn’t manage. (Van Hassel, want to kill myself. 1982). Have you ever held on to something for so long Running Head: BIOPSYCHOSOCIAL PAPER 16 you got tired of holding on to it, you just let go?” “Well, that’s what happened to me, I got tired of holding the gun and it went off.” RN: “You did not have suicidal thoughts at the time?” M.S. “No, not at all. Do you want to hear about my theory on time?” “If I just keep looking at the clock the time goes by so slow, but if I don’t time goes by really fast like when I am talking with you.” “You think I am crazy don’t you?” RN: “No, I just don’t understand your theories.” 4. Nurse will interact with client on the basis of things in the environment. Nurse will try to distract client from their delusions by engaging in reality- based activities. (Varcarolis, 2006). RN: “Can you remember three objects for me and I will ask Running Head: BIOPSYCHOSOCIAL PAPER 17 you these three objects again throughout our conversation?” M.S. “Sure.” RN: “The three objects are a truck, a pen, and a house.” M.S. “Ok, got it.” RN: “Now can you fold this paper in half?” M.S. “Yes.” RN: “Good, now name those three objects I told you to remember.” M.S. “truck, pen, and house.” RN: “Good.” 5. Nurse will teach client coping skills that minimize “worrying” thoughts. (Varcarolis, 2006). RN: “Do you go to the gym for activities?” M.S. “Yes, sometimes I like to go down there.” RN: “That’s good; exercise can relieve a lot of stress, on top of keeping you healthy.” Defense coping Related to Short Term Goal: M.S. will 1. Nurse will assess and 1. Intervene before client perceived lack of self- focus reality-based activity observe client regularly loses control. efficacy/vulnerability, As with the aid of for signs of increasing (Varcarolis, 2006). Evidence By M.S. has presence medication/nursing anxiety and hostility. 2. Prepares the client of Grandiose delusions and interventions by 11/23/2009 (Carpenito, 2006). RN: beforehand and denial of obvious problems “Can you rate your minimizes Running Head: BIOPSYCHOSOCIAL PAPER 18 Long Term Goal: M.S. will be anxiety from a scale misinterpreting your able to apply a variety of from 1-10?” intent as a hostile or stress/anxiety-reducing 2. Nurse will explain to aggressive. techniques on own by client what you are 3. Minimize the 12/9/2009 going to do before you opportunity for do it.(Carpenito, 2006). miscommunication and RN: “I will be asking misconstruing the you a few questions, if meaning of the that’s ok?” RN: “If message. there is anything that 4. Suspicious clients will makes you feel automatically think that uncomfortable let me they are the target of the know.” interaction and interpret 3. Nurse will focus on it in a negative manner. here and now, goal- (Varcarolis, 2006). directed topics when 5. Noisy environments encountering client’s might be perceived as defenses. (Carpenito, threatening. 2006). RN: “What did Concentrating on you do at group today?” environmental stimuli RN: will ask simple and minimizes paranoid to the point questions. rumination. (Varcarolis, RN: will speak slowly 2006). and clear so patient has a chance to process the information. RN: will give plenty of time to respond to a question. 4. Nurse will not challenge distortions or unrealistic/grandiose self expressions. The nurse will try to redirect Running Head: BIOPSYCHOSOCIAL PAPER 19 the conversation toward more neutral topics or more realistic topics about which some agreement has already been established. (Carpenito, 2006). RN: will not laugh or whisper about client, or talk quietly when client cannot hear what is being said. RN: “What type of goals do you have for you to leave HBH?” 5. Nurse will maintain a low level of stimuli and enhance a nonthreatening environment. (Varcarolis, 2006). RN: “I would like to talk to you for a few minutes, do mind if we go in the dining room where there are less people?” RN: remain quiet when waiting for a response from client. RN: remove client from areas of high stimuli when interviewing. Running Head: BIOPSYCHOSOCIAL PAPER 20 References Carpenito-Moyet, Lynda, Juall (2006). Nursing diagnosis: Application to clinical practice (11th ed.). Philadelphia, PA: Lippencott. Van Hassel, J., Bloom, L., & Gonzalez, A. (1982). Anxiety management of schizophrenic outpatients. Journal of Clinical Psychology, 38(2), 280-285. Retrieved from Academic Search Premier database Varcarolis, E. M. (2006). Manual of psychiatric nursing care plans (3rd ed.). St. Louis, MO: Elsevier.
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