Biopsychosocial paper by liamei12345

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									Running Head: BIOPSYCHOSOCIAL PAPER                                         1

                                            Biopsychosocial Paper

                                              Michelle Dearduff

                                      Kent State University, Stark Campus
Running Head: BIOPSYCHOSOCIAL PAPER                                                                                             2


       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
                                         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
                                      4. Nurse will review the
                                         areas in the treatment
                                         regimen that interfere
                                         with adherence.
                                         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
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
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                                         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
                                                                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

                                      5. Nurse will maintain a
                                         low level of stimuli and
                                         enhance a
                                         (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


      Carpenito-Moyet, Lynda, Juall (2006). Nursing diagnosis: Application to clinical practice (11th ed.). Philadelphia, PA:


      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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