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
Medication
Use in Patient
8
Side Effects
Risperdal Consta
50mg IM every two
weeks
Schizophrenia
Neuroleptic
Malignant Syndrome
(NMS), dizziness,
extrapyramidal
reactions, headache,
insomnia,
constipation, weight
gain, decreased libido
Depakote 500mg
every morning
Manic episodes
associated with
bipolar disorder
Zyprexa 20mg every
evening
Schizophrenia
Benztropine
(Cogentin) 1mg twice
daily
Extrapyramidal
effects due to
antipsychotic
medications
Hepatotoxicity,
nausea, rashes,
pancreatitis,
confusion, dizziness,
sedation.
NMS, seizures,
agitation, restlessness,
orthostatic
hypotension,
tachycardia, weight
gain, hyperglycemia,
tartive dyskinesia.
Constipation, dry
mouth, dry eyes.
Nursing Implications
Monitor for development of NMS (fever, respiratory
distress, tachycardia, seizures, diaphoresis, hypertension,
pallor, tiredness). Notify physician or other health care
professional immediately if these symptoms occur. Monitor
patient’s mental status (delusions, hallucinations, and
behavior) before and periodically during therapy. Monitor
blood pressure (sitting, standing, lying down) and pulse
before and frequently during initial dose titration. Monitor
patient for onset of extrapyramidal side effects (akathisiarestlessness; 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.
Assess mood, ideation, and behavior frequently. Monitor
hepatic function and serum ammonia concentration prior to
and periodically during therapy. Monitor CBC, platelet
count, and bleeding time prior to and periodically during
therapy.
Monitor for development of NMS, Monitor for tartive
dyskinesia, Monitor blood pressure, Monitor blood glucose
in patients with diabetes, and prior to and periodically
during therapy in patients with risk factors for diabetes.
Assess parkinsonian and extrapyramidal symptoms before
and throughout therapy. Assess bowel function daily.
Patients with mental illness are at risk of developing
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
Priority Nursing Diagnosis
Short and Long-Term Goals
Noncompliance related to an
active decision of an individual
to fully or partially nonadhere
to an agreed-on
medication/treatment regimen,
As evidence by M.S. returning
to Heartland Behavioral Health
after shortly being released on
Conditional Release which
consisted of medication
compliance. Patient states “I
did not take my meds, and
that’s why I did bad things.”
Short term goal: M.S. will
negotiate acceptable changes in
the treatment plan that he is
willing to follow by 11/23/09
Long term goal: M.S. will state
correct information about his
condition, benefits of treatment,
risks of treatment, and
treatment options each time
changes are made to their
treatment plan by 12/9/2009
10
Nursing Interventions/Actions
1.
Nurse will assess how
the patient’s disorder
and subsequent
treatments/medication
impact upon patient’s
(and family’s) lifestyle.
(Varcarolis, 2006). RN:
“Tell me how going to
groups and taking your
medications have
helped you receive level
5 privileges?” M.S.
“When I go to groups
and take my
medications, I am able
to work, and type my
book on my computer,
and I can leave HBH
with my bother.” RN:
“So when you follow
your treatment plan,
you are able to live a
better lifestyle, and
learn ways to live
outside of HBH.” M.S.
“Yes, I enjoy being able
to leave HBH with my
brother for groups.”
2. Nurse will explore with
patient their feelings
about the
Rational
1. Age, religion, cultural
beliefs, and
expectations of others
all impact on our value
system and factor into
how we make decisions.
(Varcarolis, 2006).
2. Client (family)
misperceptions about
disease/disorder or
treatments result in
faculty decision
making. (Varcarolis,
2006).
3. People need to know
that, in most instances,
medications cannot cure
them, but they can help
stabilize their symptoms
with time. Ultimately,
the final choice is with
the client. Our job is to
provide information and
effective treatment
options that best suit the
client’s lifestyle.
(Varcarolis, 2006).
4. Nonadherence is often a
symptom of an
underlying problem.
That problem must be
Running Head: BIOPSYCHOSOCIAL PAPER
11
illness/disorder and the
need for ongoing
treatment. (Varcarolis,
2006). RN: “Do you
understand that taking
your medications will
help you in leaving
HBH?” M.S. “Yes, I
know I need to take my
meds, but I don’t think I
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
identified. (Varcarolis,
2006).
5. The more complicated a
treatment plan, the more
likely is nonadherence.
The easier the regimen
is to follow, the greater
the likelihood of
compliance.
(Varcarolis, 2006).
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
Disturbed Thought Processes
Related to
Biochemical/neurologic
imbalances, As Evidence By
M.S. Grandiose delusion that
he has rewritten Einstein’s
Relativity Theory.
Short Term Goal: M.S. will talk
about concrete happenings in
the environment without
talking about delusions for five
minutes by 11/23/09
Long Term Goal: M.S. will
demonstrate two effective
coping skills that minimize
delusional thoughts by 12/9/09
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.”
1. Nurse will review to
attempt to understand
the significance of these
beliefs to the client at
the time of their
presentation.
(Varcarolis, 2006). RN:
“You stated that you
like to write.” M.S.
“Yes, I am writing a
book about the Big
Bang Theory and time
travel.” RN: “Do you
write for the HBH
newsletter?” M.S. “Yes
I do, I have an eye in
my head that is like the
dollar bill and I can see
into the future.” RN:
“What do you write for
1. Important clues to
underlying fears and
issues can be found in
the client’s seemingly
illogical fantasies.
(Varcarolis, 2006).
2. Identifying the client’s
experience allows the
nurse to understand the
client’s feelings. When
people believe that they
are understood, anxiety
might lessen.
(Varcarolis, 2006).
3. Arguing will only
increase client’s
defensive position,
thereby reinforcing
false beliefs. This will
result in the client
Running Head: BIOPSYCHOSOCIAL PAPER
15
the HBH newsletter?”
M.S. “I don’t write
much for them
anymore, but I do write
a lot in my room, I am
99.9% done with my
book, and hopefully I
can make money off of
that.”
2. The nurse will be aware
that client’s delusions
represent the way that
he experiences reality.
(Varcarolis, 2006) RN:
“Do you have friends
here at HBH that you
can talk to?” M.S. “Not
really, most of them just
think I am crazy, but I
am just really good with
numbers, they don’t
understand me.”
3. Nurse will not argue
with the client’s beliefs
or try to correct false
beliefs using facts.
(Varcarolis, 2006) RN:
“Tell me about your
incident with the hand
gun.” M.S. “I didn’t
want to kill myself.
Have you ever held on
to something for so long
feeling even more
isolated and
misunderstood.
(Varcarolis, 2006).
4. When thinking is
focused on reality-based
activities, the client is
free of delusional
thinking during that
time. Helps focus
attention externally.
(Varcarolis, 2006).
5. The implication for
therapeutic intervention
with schizophrenics,
then, is that there is a
real need for a system
that will provide the
patient with a more
effective means of
appropriately coping
with anxiety and stress.
Schizophrenics
experience more
subjective stress in daily
life than normal and
find periods of
increased environmental
stress difficult to
manage. (Van Hassel,
1982).
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 realitybased activities.
(Varcarolis, 2006).
RN: “Can you
remember three objects
for me and I will ask
Running Head: BIOPSYCHOSOCIAL PAPER
Defense coping Related to
perceived lack of selfefficacy/vulnerability, As
Evidence By M.S. has presence
of Grandiose delusions and
denial of obvious problems
Short Term Goal: M.S. will
focus reality-based activity
with the aid of
medication/nursing
interventions by 11/23/2009
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.”
1. Nurse will assess and
observe client regularly
for signs of increasing
anxiety and hostility.
(Carpenito, 2006). RN:
“Can you rate your
1. Intervene before client
loses control.
(Varcarolis, 2006).
2. Prepares the client
beforehand and
minimizes
Running Head: BIOPSYCHOSOCIAL PAPER
Long Term Goal: M.S. will be
able to apply a variety of
stress/anxiety-reducing
techniques on own by
12/9/2009
18
anxiety from a scale
from 1-10?”
2. Nurse will explain to
client what you are
going to do before you
do it.(Carpenito, 2006).
RN: “I will be asking
you a few questions, if
that’s ok?” RN: “If
there is anything that
makes you feel
uncomfortable let me
know.”
3. Nurse will focus on
here and now, goaldirected topics when
encountering client’s
defenses. (Carpenito,
2006). RN: “What did
you do at group today?”
RN: will ask simple and
to the point questions.
RN: will speak slowly
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
misinterpreting your
intent as a hostile or
aggressive.
3. Minimize the
opportunity for
miscommunication and
misconstruing the
meaning of the
message.
4. Suspicious clients will
automatically think that
they are the target of the
interaction and interpret
it in a negative manner.
(Varcarolis, 2006).
5. Noisy environments
might be perceived as
threatening.
Concentrating on
environmental stimuli
minimizes paranoid
rumination. (Varcarolis,
2006).
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.