Nursing Care of the Patient with Schizophrenia

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Psychosis
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Loss of touch with reality
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Schizophrenia
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One way psychosis manifests Diagnosis associated with psychosis (>6 months)
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Schizo
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Not always meaning schizophrenia but loss of touch with reality
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Schizophreniform Disorder
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Exact same s/s as schizophrenia but doesn’t meet the time requirement (>1 month < 6 months)
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Schizoaffective Disorder
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Same s/s of schizophrenia plus depression or bipolar disorder
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Other Psychotic Disorders
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Don’t meet the criteria for schizophrenia, schizophreniform, or schizoaffective disorder Not sure what it is Used to be called not otherwise specified
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Delusional Disorder
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Refers to a condition associated with one or more nonbizarre delusions of thinking
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Personality Disorder
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Schizotypal personality disorder Schizoid personality disorder Paranoid personality disorder *Not related to schizophrenia but have something to do with loss of touch with reality or odd eccentric behaviors*
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Epidemiology/Statistics
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Effect 1% of people world wide (1:100) One of ten leading disabilities world wide 50% disabled for life 5-10% commit suicide Equal prevalence in men and women Earlier onset for men Late teens/early 20’s when actual diagnosis is made but there may be prodromal symptoms before then Frequent lengthy hospitalizations Have for life, no remission 1/3 homeless 15% don’t respond to medications 70% are only partial responders to medications 20% shorter life expectancy (with all mental health disorders) partly due to medications side effects
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Side Effects of Medications
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Increase chronic illness rate in almost every body system 3 times likely to develop hypothyroidism 8 times more likely to have hepatitis C Twice as likely to have asthma, diabetes, COPD, peripheral vascular disease 3 times more likely to be a smoker
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History & Myths
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Used to be believed it was caused by a certain type of mothering pattern (distant/didn’t provide enough love/no connection)
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Contributing Factors
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Physiological Environmental Psychological Sociocultural/spiritual
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Physiological
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Genetics Dopamine hypothesis
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Genetics
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1/3 people have strong genetic prevalence but up to 2/3 have no family history at all (biological) 9 times greater risk for developing if brother/sister have 10-15% risk for developing if one parent has 45% risk of developing if both parents have 50% risk of developing if twin has it *Stronger genetic link with bipolar than schizophrenia*
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Dopamine Hypothesis
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Doesn’t effect everyone Used to develop medications Hypothesis is there is too much dopamine in the brain which causes brain function to not work properly and the patient can’t interpret reality properly Medications block dopamine from attaching to NT and decrease dopamine in the brain which can cause other issues
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Environmental
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Exposure to psychoactive substances If the brain is predisposed to developing schizophrenia and exposed to a psychoactive substance, likely to develop schizophrenia
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Psychological
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No link
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Sociocultural/Spiritual
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No link
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Signs & Symptoms of Schizophrenia
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Prodromal symptoms Positive symptoms Negative symptoms Cognitive symptoms
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Prodromal Symptoms
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The early symptoms and signs of schizophrenia that precede the characteristic manifestations of acute, fully developed schizophrenia
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Positive Symptoms
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*Symptoms that are excess in behavior (added on/not typically seen)* Delusions Hallucinations Disorganized thoughts/speech Disorganized behavior
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Delusions
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*False personal beliefs that are inconsistent with the persons intelligence, cultural background. It is a fixed personal belief, do not challenge* Persecutory Grandiose Ideas of reference Thought insertion/deletion/broadcasting
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Persecutory
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Most common Someone/something is out to get them
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Grandiose
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Delusion of grandeur They are the best They are the mesiya They are Jesus
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Ideas of Reference
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IOR Patient thinks that something happening is a message for them, it is a direct reference to them
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Thought Insertion/Deletion/Broadcasting
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Patient thinks someone/thing is inserting thoughts that are not the patients own into their mind Patient thinks someone/thing is taking their thoughts from them Patient thinks that everyone can hear their thoughts
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Hallucinations
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Sensory experiences which are not perceptible by others Auditory Visual Tactile Gustatory Olfactory
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Auditory Hallucinations
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Most common Usually negative and threatening Command auditory hallucinations are potentially the most dangerous
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Visual Hallucination
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Second most common Highly unlikely to experience auditory and visual together If the patient does, suspect psychoactive substance or medical process but unlikely to be associated with schizophrenia
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Gustatory Hallucinations
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Taste something weird/bad R/O neurological problem first even if the patient has schizophrenia
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Olfactory Hallucination
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Burning smell, not pleasant R/O neurological problem first even if the patient has schizophrenia
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Tactile Hallucination
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Feel something on their body Most commonly associated with alcohol abuse or withdrawal
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Disorganized Thoughts/Speech
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Loose associations Tangentiality Perseveration Neologism Magical thinking Clang associations Word salad Mutism Echolalia
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Loose Associations
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Patient’s responses do not relate to the interviewer’s questions
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Tangentiality
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When one tends to digress readily from one topic under discussion to other topics that arise in the course of associations
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Perseveration
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Repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus
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Neologism
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Person creates new words or expressions
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Magical Thinking
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Believing that one event happens as a result of another without a plausible link of causation
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Clang Associations
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Clanging is a manner of speaking in which words are chosen for their related sounds rather than logical meanings
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Word Salad
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A confused or unintelligible mixture of seemingly random words and phrases
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Mutism
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Not speaking at all
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Echolalia
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Repeating what the speaker is saying
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Disorganized Behavior
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Echopraxia Odd dress Bizarre posturing Waxy flexibility Catatonia
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Echopraxia
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Meaningless repetition or imitation of the movements of others
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Waxy Flexibility
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Decreased response to stimuli and a tendency to remain in an immobile posture *Symptom of catatonic schizophrenia*
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Catatonia
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Immobile or unresponsive stupor
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Negative Symptoms
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Affect Apathy Asociality Avolition Anhedonia *Up until the 80’s, medications did not help with negative symptoms*
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Affect
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Flat or inappropriate mood/behavior
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Apathy
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Lack of interest, enthusiasm, or concern
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Asociality
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Don’t want to be around other people, prefer to be alone
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Avolition
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No motivation to do anything
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Anhedonia
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Loss of pleasure in things once enjoyed
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Cognitive Symptoms
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*Disturbance in memory and frontal executive functioning so thought, planning and doing* Anosognosia Memory
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Anosognosia
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Lack of insight/awareness of disease process which makes treatment a challenge
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Assessment, Diagnostic Testing, and Laboratory Values
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Neuroanatomical changes Positive and negative syndrome scale (PANSS) Differential diagnosis
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Neuroanatomical Changes
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Enlarged ventricles Frontal lobe atrophy Increased sulci
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Enlarged Ventricles
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Decreased amount of white matter in the brain making it more difficult for NT to communicate with each other
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Frontal Lobe Atrophy
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Wasting away of the frontal lobe Frontal lobe is where executive learning and thought process takes place
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Increased Sulci
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Decreased amount of white matter in the brain making is more difficult for NT to communicate with each other
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Positive and Negative Syndrome Scale (PANSS)
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Used a lot in research to see if there are changes in a patients symptoms
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Differential Diagnosis
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Delirium Substance abuse/misuse Bipolar disorder Medical Issues
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Delirium
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Post-Op looks like psychosis R/O first especially if its the patients first experience with loss of touch with reality
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Bipolar Disorder
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Manic episode might have delusions of grandeur and they may hear voices
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Medical Issues
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Neurochemical Hyperthyroidism Hypothyroidism Drug induced Metabolic syndrome Diabetes
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Evidence Based Practice/Collaboration Care
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Health promotion Nursing process Pharmacological/parenteral therapies Therapeutic measures Communication and documentation Utilization of resources Patient/family education and referral
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Health Promotion
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Early identification and treatment of disease Focus on what the patient can do Barriers to treatment Comorbidities
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Early Identification and Treatment of Disease
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What helps manage the voices? Identify triggers Music Talking to the voices, telling them to stop Reading out loud Finding strengths Hobbies
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Focus On What The Patient Can Do
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A patients perceived consequences Problem solve around what would help them achieve their goals Supportive employment Clubhouse Finding something important to them Checking in with someone daily
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Barriers to Treatment
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Anosognosia Access to health care/services and transportation Side effects of medicatons What the patient thinks are barriers
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Comorbidities
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*See side effects of medications* Nicotine/caffeine
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Nicotine
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When the patient is in the hospital, they need to receive higher doses of their medications if they are a smoker. The patch is metabolized differently than smoking which suppress some symptoms
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Nursing Process
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Nursing diagnosis: disturbed thought process
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Nursing Diagnosis: Disturbed Thought Process
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Maintain safety Establish trust
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Establish Trust
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Consistent caregivers Suggest collaboration
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Pharmacological/Parenteral Therapies
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*See Psychopharmacology study set*
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Therapeutic Measures
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Milieu therapy Level of care
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Level of Care
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Inpatient, IOP/PHP, day program, VNA
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IOP
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Intensive outpatient program
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PHP
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Partial hospitalization
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Communication and Documentation
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Therapeutic communication
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Therapeutic Communication
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Acknowledge Empathize Distract Redirect
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Utilization of Resources
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Information technology Quality indicators TJC national patient safety goal
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TJC National Patient Safety Goal
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The joint commission *Find out which individuals severed are most likely to try to commit suicide*
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Patient/Family Education and Referral
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Patient-specific signs and symptoms of relapse and plan Effective management of symptoms Managing side effects of medications Social skills training Supported employment program Supervised housing Psychiatry/social work Community mental health agency
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Community Mental Health Agency
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Strafford county: community partners Rockingham county: seacoast mental health

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