np revised

8/7/2019 np revised.

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I. ASSESSMENTA. General Data

Patients Initials: T.P. Sex: Female

Address: Pasay

Age: 62 years old Civil Status: Single

Date of Birth: December 9, 2010

Date of Admission: October 21, 2006

Order of Admission: Brought by a relative

Informant: Nurse, Patient

B. Presenting Problem

1. Interview to the Patient:After establishing rapport with the patient, she was very open when initially asked about her thoughts on why she is at the home care. She explained

that her brother suggested putting her in home care because ofher constant eating and her hearing voices. When asked further about her eating habits

before she was admitted, she said she just kept eating without even feeling hungry. Upon questioning about her hearing voices, she avoided thequestion and moved on to another topic. During the interview, the patient spoke quickly and happily while making eye contact, but when asked about

sensitive topics like her fathers death she starts looking side to side and became restless. The patient stated that she used to work at her brothers firm

in Pasay for 5 years as a secretary and messenger.

2. Interview to Nurse/Family:According to the nurse-on-duty, T.P. was brought to Divine Mercy by his brothers wife.

3. The Problem:T.P. was diagnosed with having Bipolar Disorder. The patient has been experiencing manifestations for 40 years. T.P. speaks quickly and sometimes

sounds as ifshe feels pressured to speak more.

C. Past Psychiatric Mental History:


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According to the nurse and her brother, E.L was first seen with an abnormal behaviour since she was a college student. She was quiet and alone most of

the time. She experienced auditory, visual and verbal hallucinations. According to her brother, E.L. verbalized seeing people staring at her, following her

or sometimes, talking to her. Few days after this, the patient still manifested the same symptoms. Because of this, the patients family decided to bringher to National Center for Mental Health. After 3weeks of being admitted, E.L. was ordered for discharge already and highly encouraged to proceed to

home management. The patient and her relatives were instructed to comply with the take-home medications of the patient. Then after 20 years of

home management, E.L stopped taking medications thinking that she is already fine. She was then admitted to Timog Residences for observation and

care.

D. Mental Status Examination

Comprehensive Mental Status Examination

1. OrientationT.P. was oriented with persons, place, and time. When she was asked what time it was, who she was talking to and where she is, she answered correctly.

2. SensoriumThe patient was conscious and active during the interview. She was attentive, she answers questions asked to her. She maintained partial eye contactduring the interview during sensitive topics but maintained good eye contact when she was in a good mood. She answered questions in English most of

the time and was very articulate with her speech.

3. Appearance and Behavioura. Facial expression During conversations the patient would be smiling most of the time. Only when she is asked sensitive

topics will she frown and look down. There are also some days where she was in a depressed or frustrated mood throughout

the whole activity because ofthings that would happen the day before or ifshe wasnt allowed to go home.b. Gestures, posture - During conversations the patient was restless most of the time. She always moves her fingers or

pretends like she is writing on her leg. She would look side to side when trying to avoid certain topics.

c. Dress The patient wears clean clothing and slippers, but she wears excessive white powder on her face with excessivebright lipstick everyday.

d. Reaction to caregivers She smiles when seen by the student nurse, and is cooperative when asked questions and asked tojoin activities.


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4. Speech and CommunicationThe patient answers questions in English and speaks very quickly. She is articulate in her speech, but sometimes sounds like she is pressured to speak.

5. Mood or AffectPatients mood is always initially happy and energetic. When she gets tired or if she was frustrated with a previous situation she becomes irritable or

silent.

6. ThinkingThe patient experiences mood swings and states that she hears voices. When asked about what she hears, she asks to not talk about it and change the

topic. Her thought process is aqequate most ofthe time because when she is asked a question, she answers with relevant answers and quickly.

7. PerceptionThe patient exhibits manifestation ofhallucinations.

Perception- T.P. experiences auditory hallucinations.

8. MemoryThe patient has good memory. She remembers exact dates of important events. She remembers her birthday, the death of her father and remembers

many activities she did when studying in school.

9. InsightT.P. is aware of her illness and why she is there. She says that she feels inspired to get better and live a good life because the student nurses motivate

her. She believes that ifshe stays good she will be able to be discharged.

10.History


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The patient was born in Manila, and is the fourth child of five children. She was a very diligent student at St. Scholastica from grade school to high

school. Among all her family members, she was the closest to her father. The time she was depressed the most was when he died. T.P. joined the glee

club and drama club of her school and lead some of the plays like MacBeth and A Midsummer Nights Dream. She wasnt allowed to join any schoolparties, like prom or birthdays. T.P. also chose not to use makeup, and always dressed conservative. She never went on a date, but had a crush on a nun

that taught at her school. She stated that she saw her on TV one morning and recognized her immediately. After she graduated, she went to college to

study BS Mass Communication at Philippine Womens Universtiy for two years. According to her, she wasnt able to finish because she became sick.

Following the death of her father, her brother asked her to come work at his firm as a secretary and messenger. She said she worked there for 5 years

and then she stopped after she started getting sick again. Afterward, she stayed home with her mother. Her brother decided to admit her into home

care when she started becoming violent with the maids at her house and when she stated that she started hearing things that others cant.Another

problem that she was experiencing was that she was eating too much. She ate even if she wasnt hungry. She was admitted in Divine Mercy on October

21, 2010.

E. Family Assessment

Initials Age Sex Relation OccupationEducational

Attainment

NP 89 F Mother None Graduate

LP (deceased) 72 M Father Businessman Graduate

RP 68 M Brother Businessman Graduate

AP 66 M Brother Businessman Graduate

NP 63 F Sister Businessman Graduate

JP 57 M Brother Businessman Graduate

G. Heredo -Familial Illness


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MATERNAL SIDE PATERNAL SIDE

Grandparents GrandparentsLola (Alzeimers) Lolo Lola Lolo

Mother Father

RP AP NP TP JP

Maternal: Hypertension Paternal: Hypertension

I. Physical Examination (Taken on December 27,2010; 0900H)

General Survey:

The patient physically looks demure and reserved. She is conscious; however she has a blunt affect and a very slow response mechanism in terms of

speech. When being asked with simple questions, she can answer at least after 2 to 3 seconds. When asked with complex questions, she most often tries

to think for the answer for at least 7-10 seconds then forgets the question or forgets that she was asked a question. In terms ofher answers, there were

times that her answers were not parallel with the question which may justify the patients disturbed thought processes caused by her illness-

schizophrenia. The patient doesnt exhibit anxiety but there are times that she is aloof, most especially when games are being held for them to join in.

Most ofthe time, she fixes her selfand keeps it neat and tidy for her to look beautiful. Lastly, her body movements are very slow and sluggish.

Height: 50 feet Actual Weight: 125 lbs/ 56.8 kgs

Actual Height: 50 feet BMI: kg = 56.8 kgs = 25.24


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m2

2.25m2

BMI: Pre- Obese/ Obese Class 1

Initial Vital Signs:

Blood Pressure: 120/90 mmHg Respiratory Rate: 21 cpm

Pulse rate: 78 bpm Temperature: 36.6 C

Regional Examination:

1. Skin

Inspection: Uniform tan skin in exposed areas Excessive powder on face

Palpation:

Uniform temperature and within normal range When pinched, skin springs back in original state Tenderness is not present on any part

2. NailsInspection:

Fingernails has convex curvature Angle ofthe plate about 160 Thin nails Intact epidermis

Palpation:

Good capillary refill when blanch test is performed3. Head and Face

Inspection:

Symmetrical facial features Rounded skull No edema in the eyes Eyes are symmetrically aligned


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4. Eyes

Inspection:

Hair in the eyebrows evenly distributed Eyebrows symmetrically aligned Equal movement ofeyebrows Skin around the orbit ofthe eye has wrinkles Eyelashes are equally distributed and cruve slightly outward Skin in the eyelashes is intact; no discharge and discoloration found Lids close symmetrically Approximately 14 involuntary blinking per minute Bilateral blinking Sclera is white Pupil reaction to light and accommodation is normally symmetrical and equal but movement is a bit slow Pupil size is 3mm Illuminated pupil constricts but takes more time to constrict Pupil constrict when looking at near objects Pupil dilates when looking at far objects Pupil fully converge when near object is moved toward nose Able to read newsprint up close Unable to read things from a distance

Palpation:

No edema in lacrimal gland Client blinks when cornea is touched

5. Ears

Inspection:

Color ofears are light brown Ears are symmetrical Auricles aligned with the outer canthus ofthe eyes Skin ofear is resilient

Palpation:

Pinna recoils after folded6. Nose


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Inspection:

Symmetric No discharges No nasal flaring Pink mucosa No lesions Nasal septum intact and in midline

Palpation:

Air moves freely as the client breathes through the nares Facial sinuses around the nose not tender

7. Mouth and Throat

Inspection:

Pink in color Moist oral mucosa Can purse lips Gums are slightly dark in color Client has dentures for upper teeth

Bottom teeth are spaced apart and some are missing Tongue is in the center Tongue is pale pink in color with thin whitish coating No lesions at oral mucosa Papillae are not that evident Tongue moves freely Light pink, smooth soft palate Uvula in midline

Palpation: Gag reflex is present

8. Neck

Inspection:

Muscles are equal in size Head is at the center Head movements are coordinated


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Thyroid gland is not visiblePalpation:

Resistance o

fthe neck muscles are good

No palpable lymph nodes Trachea at central placement in midline ofthe neck Thyroid gland ascends during swallowing Thyroid gland is palpable

9. Spine

Inspection:

Curvature o

fthe spine is straight

Movement ofspine is freely performedPalpation:

There is no tenderness but pain is present at the lower back Mass or lumps are not present

10. Thorax and Lungs

Inspection:

Absence o

funeven movement in the chest wall

No presence ofscars and lesions Contour ofthe chest is symmetrical Entire thorax has normal expansion and symmetry Quiet, rhythmic and effortless respirations

Palpation:

Smooth and warm to touch A

bsence of

lumps, masses, and pulsations Full and symmetric chest expansion Full symmetric excursion; thumbs normally separate 3 to 5cm Tactile fremitus is symmetrical upon palpation No presence oftenderness

Percussion:

Resonant sound is produced during percussionAuscultation:


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Vesicular breath sounds are heard upon auscultation Absence ofshallow or labored breathing

Respiratory rate of

17cpm

11. Heart and Neck vessels

Inspection:

No presence ofvisible pulsationsPalpation:

Chest wall is warm to touch

Auscultation:

Apical pulse of78 beats per minute No presence ofmurmurs

12. Breasts

Refused13.

AbdomenInspection:

Round and flabby Abdomen is symmetrical No lesions and inflammation Umbilicus is round

Auscultation:

Presence ofsoft gurgling sounds which is 20 times per minute Bowel sounds are audible

Palpation:

Dull sound heard over solid masses or internal organ like liver Tympanic sound heard over the stomach

Percussion:

Soft and flabby


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There are no presence ofabdominal tenderness and masses Relaxed abdomen

There is no presence of

discomfort during palpation

Absence ofany abdominal distention14. Extremities

Inspection:

Muscle size is equal on both sides No contractures noted Tremors are not present on either hand

No bone deformities

No joint swelling as well as tenderness Both extremities showcase equal muscle strength

Palpation:

Upper and lower extremity muscles are slightly firm Upper and lower extremity muscle strength is equal Edema is not present on both extremities

15. Genitals Refused

16. Anus and Rectum

Refused

17. Neurologic Exam

Cerebral Function:

Over- all appearance: The patients physical appearance is very demure and reserved. Her face shows a dull/ bluntaffect. Her head is erect and facial features are symmetrical. She walks normally, with both lower extremities being used

and with proper posture but has a quick pace. The patient is energetic when it comes to performing activities.

Level ofConsciousness: Alert


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Can alternately supinate and pronate hands but at a slow paceSensory System:

The client perceives pain, she can discriminate which is blunt and sharp. The client can perceive all stimuli. Hot and Cold temperature is correctly differentiated The client has good 2 point discrimination; the client perceived the stimulus made at his back Point localization is also good Light touch sensation is easily sensed.

Reflex: Bicep reflex present at the right arm Triceps reflex present at the right arm Patellar reflex is present at the right knee Superficial reflexes were not assessed

Cerebellar Function:

The client can stand erect and has a good posture Moves feet afar to remain stance.

Maintains stancefor 10 seconds

Can maintain balance on toes or heels The client can walk across without difficulty Can alternately supinate and pronate hands at a slow pace The client was able to point the nurses finger after pointing his nose.

II. PERSONAL/SOCIAL HISTORYThe patient is interested in cooking and sewing. Whenever she gets to go home overnight or for a couple ofdays, she states that she and her mom make

pastillas and polvoron. Something that she stated repeatedly was that when her brother gives her money she buysfabric immediately to sew.

In the ward she loves to play cards with her co-patients or by herself. She also states that she loves to exercise and that she leads the exercises every

morning. When she has nothing else to do, she walks around and looks out the window. During the day time, she likes to read prayer books but she cant

read at night because ofpoor eyesight.


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Before being admitted into the hospital she said that she doesnt have any contact with her old school friends and that she stayed home most of the

time. She states that she is friends with many people in the ward. There are times where other patients act violently towards her and she doesnt know

why because she doesnt do anything to off

end them. She hasfriendly relationships with the health care pro

fessionals o

fDivine Mercy.

III. ENVIRONMENTAL HISTORY

T.P. states that she lives in an exclusive subdivision in Pasay near UN. Her house is two-storeys with four bedrooms. She lives with her mother, brother

and his family with maids and a driver.

IV. OB GYNE HISTORY

Not applicable

V. PEDIATRIC HISTORY

Not applicable


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VII. DRUG STUDY

NAME OF DRUG INDICATION MODES OF ACTION SIDE/ADVERSE EFFECTSNURSING

CONSIDERATIONS PATIENT TEA

Generic name:

Clozapine

Brand name:

Leponex

Classification:

Atypical

Antipsychotic

Dosage, Route,

and Frequency:100mg/tab HS

ySchizophrenia in patientunresponsive to other

therapies.

yUnclear. Thought tointerfere with dopamine

binding in limbic system of

CNS with high affinity for

dopamine receptors.

y CNS: sedation, drowsiness,dizziness, vertigo, insomnia,

disturbed sleep, nightmares,

restlessness.

yCV: tachycardia, hypotension,hypertension, chest pain

y EENT: visual disturbancesy GI: dry mouth, constipation,

nausea, vomiting, excessive

salivation

y GU: urinary frequency orurgency, urine retention

y Respi: respiratory arrest

- Patientmonitoring

1. Monitor WBCweekly for 6

months

2. Monitor ECGand liverfunction test

3. Ifdrug mustbe

withdrawn

abruptly,

monitor

patient for

psychosisand

cholinergic

rebound

(headache,

nausea,

vomiting and

diarrhea)

1. Tell patient todisintergrating

dissolve in mo

2. Advise patientimmediately r

onset of letha

weakness, fevthroat. Malais

membrane ulc

signs and sym

infections.


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NAME OF DRUG INDICATION MODE OF ACTION SIDE/ADVERSE EFFECTS NURSING CONSIDERATIONS PATIENT TEA

Generic name:Versant

Brand name:

Modezine

Classification:

Antipsychotics

Dosage, Route,

Frequency:

0.5cc q 2 weeks

yManagement ofschizophrenia, mania &

other psychoses.

yFluphenazine decanoateblocks postsynaptic

dopamine D1 and D2

receptors in the

mesolimbic system and

decreases the release of

hypothalamic and

hypophyseal hormones. It

reduces aggressiveness

with disappearance of

hallucinations and

delusions.or increase in

adenyl cyclase function

depending on the

proportion of regional G-

proteins.

y Tardive dyskinesiay Sedationy Mental confusiony Hypotensiony Hyperprolactinaemia

leading to galactorrhoea

and amenorrhoea in

women

y Loss of libidoy Impotence and sterility

in males.

y Allergic reactionsy Cholestatic jaundicey orneal and lens depositsy Skin pigmentation.y Potentially Fatal:

Agranulocytosis;

neuroleptic malignant

syndrome.

1. Check if patient has anyextrapyramidal symptoms

(dystonic reactions &

akathisia are common).

Occasionally, galactorrhea,

augmentation of epilepsy,

epigastric pain or jaundice.

May release

catecholamines, use w/caution in

pheochromocytoma.

2. Check for any history of

hypersensitivity to the drug

3. Rotate injection sites

4. Check patients prolactin

levels (which may persist

after chronic admin.)

1. Tell patient tosunlight exposure

2. Tell patient to

eye examinations

long term therapy

3. Tell patient tha

taken with or with

4. Tell patient t

observed adverse

the health care te


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VIII. NURSE- PATIENT INTERACTIONS

Date: January 3,2011 January 24,2011

DAY 1

Orientation Phase

NURSE PATIENTTherapeutic

Communication Used

Inference

Nurse ReactionVerbal Non-verbal Verbal Non-verbal

Good Morning

maam Thelma, Im

Bobbie. I will be your

student nurse for 3

weeks every

Monday, Tuesday

and Wednesday.

The nurse

greeted the

patient with a

smile.

Hello.

Goodmorning.

Isnt that a boys

name?

The patient

greeted the

nurse smiling.

y Offered self y In order to helpbuild rapport/trust

with the patient

y Patient is veryfriendly and has no

problem in

communicating.

Are there any

problems that you

would want to talk

about maam?

Making an

eye contact

the thing I am

worried about is

wondering who

will take care of

me when Im

older already

The patient

answered with

head bowed

down and a

little smile.

y Offered generalleads

y Introducedunrelated topics

y To help the patientgive answers with

many details,

instead of just

asking for yes/no or

dates and names.

y Patient has a hardtime talking about

the death of his

father because she

is very close to him.

What makes you

think the reason

why youre here is

maam?

Making an

eye contact

Because my

brother doesnt

like me eating

all the time and

I can hear

voices.

Smilling making

an eye contact

y Exploringy Offered general

leads

y To help thepatient becaome

more comportable

again and

y The patient is fullyaware.


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communicate

more.

y To find outwhat/how aware

the patient is of

her situation.

Working Phase


Communication Used

Inference


Maam what mood

are you usually in?

Are you changing

moods?

Eye contact Im happy,

sometimes sad.

Mostly when im

alone.

Not smilling

making eye

contact

y General leads y To be able to heardetailed answers.

Patient does not want to

be idle. She always

wants something to do.

What do you do to

help yourself not to

be sad?

Eye contact I play cards with

myself or my co

patients or walk

around the

ward

Smilling y Encouragingdepth of

perceptions.

y To be able to findout how patient

deals with different

scenarios.

y Patient tries to findactivities that will

entertain her in

order to avoid

boredom.

How were you like

when you were

young po?

Eye contact I was simple I

dont go to

parties or dates

and I dont wear

make up.

Eye contact y Placing in timesequence

y To be able to findout how the

patient was like

when she was

younger and to

y Patient was moresimple and

quitewhen she was

younger and

develop more ofher

confidencewhen she


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find

inconsistencies in

her story.

got older.

Why maam? Eye contact I dont enjoy

lang, but now I

wear make up

because im

older na.

smilling y Offeringgeneral

leads.

Termination Phase


Communication Used

Inference Nurse Reaction

Verbal Non-verbal Verbal Non-verbal

Maam its your

lunch time already

you eat a lot maam

so you will be strong

and wont be sick.

The nurse

smiles and

puts her hand

on the

patients

shoulder.

Thank you so

much bobbie!

The patient

smiles and

waves

goodbye.

y Givinginformation

The nurse shifts the topic

and terminates the

conversation. The nurse

terminates the interaction

with positive gestures and

encourages the patient to

eat.

The patient is calm when it

comes to good byes and

doesnt show any bad

emotions.

Bye bye maam we

will see each other

again tomorrow po.

Take care.

The nurse

smiled and

bid goodbye.

. The patient

smiled.

y Givinginformation

The nurse finished the

conversation with a nice

smile so the patient will not

feel that the nurse does not

want to talk to her anymore

The patient is happy when

she knows that we will see

each other tomorrow.


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DAY 2

Orientation Phase


communication used

Inference Nurse Reaction


Hi, maam!Kamusta na po

kayo?

The nursegreeted the

patient with a

warm smile.

Okay naman,bobbie.

The patientgreeted the

nurse with a

half smile,

bowing down

as well.

y Givinggeneral

leads

To be able to hear detailedanswers.

The patient is okay she wantsto talk a lot.

Kamusta naman po

yung party niyo

kagabi?

The nurse

asked the

patient

politely, with

a smile.

Masaya naman.

Nakakapagod.

Pero sila lang

ang sumayaw.

The patient

gave the nurse

a smile while

answering her

question.

y Givinggeneralleads

To be able to hear detailed

answers.

Patient is shy to join she is

not used in socializing in that

way.


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Working Phase


Communication Used

Inference


Maam what mood

are you usually in?

Are you changing

moods?

Eye contact Im happy,

sometimes sad.

Mostly when im

alone.

Not smilling

making eye

contact

y General leads y To be able to heardetailed answers.

Patient does not want to

be idle. She always

wants something to do.

What do you do to

help yourself not to

be sad?

Eye contact I play cards with

myself or my co

patients or walk

around theward

Smilling y Encouragingdepth of

perceptions.

y To be able to findout how patient

deals with different

scenarios.

y Patient tries to findactivities that will

entertain her in

order to avoidboredom.

How were you like

when you were

young po?

Eye contact I was simple I

dont go to

parties or dates

and I dont wear

make up.

Eye contact y Placing in timesequence

y To be able to findout how the

patient was like

when she was

younger and to

findinconsistencies in

her story.

y Patient was moresimple and

quitewhen she was

younger and

develop more ofher

confidencewhen she

got older.

Why maam? Eye contact I dont enjoy

lang, but now I

wear make up

because im

Smilling y Offeringgeneral

leads.


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older na.

Termination Phase

NURSE PATIENTINTERPRETATION ANALYSIS


O, maglulunch na daw po

kayo. Kain po kayo madami

ha. Para po glowing and mas

beautiful.

The nurse smiles

and puts her hand

on the patients

shoulder.

Thank you Bobbie.

Thank you sa inyo.

Ingat.

The patient smiles

and waves goodbye.

The nurse shifts the topic and

terminates the conversation. The

nurse terminates the interaction with

positive gestures and encourages the

patient to eat.

Giving information is making availa

client needs. Informing the patient

or her knowledge about a ce

information builds trust with the pa

Presenting reality is offering the

which is real. When it is obvioumisinterpreting reality, the nurse

real. The nurse does this by

expressing his or her perceptions

the way ofarguing with the client o

experience. The intent is to indicat

of thought for the client to conside

the patient that he or she is wrong.


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Bye, maam G. Ingat po kayo!

Balik po ulit kami bukas.

The nurse smiled

and bid goodbye.

. The patient smiled. The nurse finished the conversation

with a nice smile so the patient will

not feel that the nurse does not want

to talk to her anymore.

Giving information is making availa

client needs. Informing the patient

or her knowledge about a ce

information builds trust with theinformed the patient that she wi

next day to be with her again, for t

to prepare her for the next day.

DAY 3

Orientation Phase


Communication Used

Inference


Good morning

maam! Sorry po I

wont be able to be

with you todaybecause I am sick.

Smiled then

prowned

Oh! Why dont

you have a

voice? You drink

ginger tea!You get well ha!

Show concern y Offered self y I let my patientknow that I will be

with her when I am

better, so that sheknows im concerned

for her.

y Patients showsconcern for feelings

and open to building

trust.


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X. NURSING CARE PLANS

AssessmentPsychiatric Nursing

DiagnosisPsychodynamics Goals & Objectives Nursing Interventions Rationale Ev

Subjective

Nurse: Ano po

bang

pakiramdam

niyo kapag po

naiisip niyo po

yung pamilyaniyo?

Patient: Minsan,

naiiyak ako kasi

nalulungkot

ako. Galit kasi

sakin kuya ko

kaya ako dinala

dito eh

Objective:

General

appearance

y Well-groomed

Risk for loneliness

related to physical

isolation

Has poor social interaction skills

Does not indulge in any social

activities

Does not interact well with new

acquaintances

Does not feel comfortable talking

to the opposite sex

Needs to be encouraged and

pleased before joining any

activities

After 2 days ofnursing

interventions, the

patient:

y Should be able tounderstandreasons for her

loneliness.

y Should havebetter

interactions with

other patients.

Should be able to

identify diversional

activities that could bedone when feeling

lonely.

Independent

y Support expression ofnegative perceptions of

others and whether client

agrees.

y Identify individualstrengths, areas of

interest

y Provide opportunities forinteractions in a

supportive environment

during initial attempts to

socialize.

y Let client know thatloneliness can be

overcome.

y Determine degree ofdistress, tension, anxiety,

y Provides opportunity forclient to clarify reality of

situation, recognize own

denial.

y Provide opportunities forinvolvement with others.

y Helps reduce stress,provides positive

reinforcement, and

facilitates successful

outcome

y It is up to the individualto build self-esteem and

learn to feel good about

self.

y Most people feel lonelyat some time in their

After 2

interven

was fu

patient:

yWas underfor he

yHad intera

other

Was ab

diversion

that co

when fee


25/30

y Good posturey Some eye

contact

yAppropriatefacial

expression

Sensory

&Cognition

The patient rarely

forgets the

question that I

ask.

Does not indulge in any group

activities sometimes

Has low self-esteem

Lacks interest and pleasure in any

social activities and interaction

Prefers to be alone

Risk for loneliness

restlessness present.

y Discuss individualconcerns about feelings of

loneliness and

relationship betweenloneliness and lack of

SO(s). Note

desire/willingness to

change situation.

y Encourage to join gamesand other social activities

y Allow patient access todiversional activities.

lives related to

situational occurrences

that engender these

feelings which arenormal in the

circumstances.

y Motivation can Impedeor facilitate achieving

desired outcomes.

y Presents an opportunityto interact with other

people.

y Diverts the attention ofthe patient from feeling

of loneliness.

yRef. p. 449-450 Nurses

Pocket Guide 11th

Edition byDoenges, Moorehouse and

Murr.


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Subjective:

Nurse: kamusta

naman mo kayo

pag kasama nyo

po pamilya nyo?

Patient: Masaya

sana kung di langsana kasama kuya

ko sobrang galit

ako sakanya

talagang

masasaktan ko

siya siya kasi nag

dala sakin ditto

galit kasi siya

sakin ehh.

Objective:

y shortattention

span

y the patienthas labile

affecty Change of

moods

y Poorconcentration

regarding

specific topics

y easily

Risk for violence r/t

hostile and angry

behavior.

trauma with his brother

failure to feel the love from his

brother

Decreased

self-esteem

Feeling ofpurposelessness

And Poor interpersonal

relationships

Lack of

interests andcommitments

anger is build up

Emotional changes

Risk for violence

Short Term:

After 3 days ofnursing

interventions, the

patient will be able to:

a. identify her ownmaladaptive coping

behaviorsb. identify available

resources and

support systems.

c. describe and initiatealternative coping

strategies

describes positive

results from new

behaviors

Independent

y Provide Safety for theclient.

y Assess degree ofdelusion

y Assess degree ofdisorientation to place,time, person and

situation regularly and

frequently.

y Approach the client in aslow and calm way also

maintain facial

expression andbehaviour that are

consistent with the

verbal statement

y Patient with delusionare prone to accident

because of the way

they think. Make sure

that you provide safety

without being over

protected

y It will determine theeffectiveness of the

drug and can help for

further treatment or

observation

y It will determine theamount o

freorientation and

intervention the

patient will need to

evaluate reality

accurately.

y A calm approach helpsto avoid distorting the

clients sensory

perceptual field whichhelp to promote

disturbed thoughts and

perceptions. The client

with disturbed thought

process may have

difficulty in interpreting

correct meanings. Ifthe

nurse misrepresents

After 3

intervenpatient:

y Be fy Dem

decr

leve

y Respbase

initia

y Intebase

y Sustand

to co

activ


27/30

distracted

y Encourage patient toverbalize feelings.

Assist to identifycausative and

contributing factors.

Assist to reduce oreliminate causative

and contributing

factors

y Offer a clear, simple

explanation of

environmental events,

activities and the

behaviors of other

clients as necessary.

Dependent

y Determining andexplaining Drugs

a. Drug useb. Effects of Drug,Therapeutic and

Non-

Therapeutic(side

Effects)

y Clozapiney Quilonium

intent with a conflicting

or double message.

y Encouraging patient torelease what she feels

will help her to relieve

her anxiety or other

burden that she is

carrying in her mind.

y Clear directexplanations of

environment events

help to lessen the

clients suspiciousness

and fear or mistrust of

the surroundings and

others. This can

prevent aggressive

behavior.

y Determining the drugcan help the nurse to

have a backgroundknowledge on possible

problem that the client

is experiencing and

explaining the effects

of drugs can help

establish a good

rapport, a good

rapport can lead to


28/30

y Modezine good relationship anda trustworthy

environment and

having a trustworthyenvironment can help

the client to open

feelings, fear or

depression that she is

experiencing.

Nurses Pocket Guide.

Doenges, Moorhouse,

Murr. 11th

Edition.



Subjective:

Ako, I dont

remember. All I

know is I want to

get out of here. I

want to be with

my mother. Gusto

ko pamilya ko

kasama ko. Nurse,pauwiin mo na

ako.

Minsan, naiiyak

ako kasi

nalulungkot ako.

Sana hindi na lang

ako nagpunta dito

Ineffective coping

related to

emotional liability

associated with

manic behaviour

Makes an attempt to cope with

the ways ofthe world

Absence ofproper guidance and

encouragement especially from

parents

Fails to identify own beliefs and

principles

After 3 hours of

nursing intervention

the patient will be

able to

d. identify her ownmaladaptive copingbehaviors

e. identify availableresources and

support systems.

f. describe and initiatealternative coping

strategies

Independent:

y Assess for presence ofdefining characteristics

y Assess available oruseful past and present

coping mechanisms.

Behavioral andphysiological

responses to stress

can be varied and

provide clues to the

level of coping

difficulty.

Successful adjustmentis influenced by

previous coping

success. Patients with

history of maladaptive

coping may need

After 3

interven

was able

a. Identifmalad

behav

out

behavon mo

strateg

b. Identiresour

system


29/30

para naaalagaan

ko yung mommy

ko. Matanda na

un at may sakitpa.

As verbalized by

the client.

Objective:

y Decreaseduse of social

support

y Poor EyeContact

y Restless

Confusion on what role to pursue

Tries to explore ways to identify

interests

Failure to realize what to take

Feelings offrustration

Depression

describes positive

results from new

behaviors

y Provide opportunities toexpress concerns, fears,

feelings, and

expectations.

yEncourage patient toidentify own strengths

and abilities.

y Encourage patient toseek information that

increases coping skills.

y Provide information thepatient wants and

needs. Do not provide

more than patient can

handle.

y Provide outlets thatfoster feelings of

personal achievement

and self-esteem.

additional resources.

Likewise, previously

successful coping skills

may be inadequate inthe present situation.

Verbalization of actualor perceived threats

can help reduce

anxiety.

During crises, patientsmay not be able to

recognize their

strengths. Fostering

awareness can

expedite use of these

strengths.

Patients who are notcoping well may needmore guidance

initially.

Patients who arecoping ineffectively

have reduced ability

to assimilate

information.

Opportunities to roleplay or rehearse

appropriate actions

can increase

confidence for

behavior in actual

situation.

by p

self-he

availab

c. describalterna

strateg

manife

o provioppo

expre

fears,expec

o identstren

abilit

o seekithat iskills

o adeqbalan

d. describresults

behavmanife

o expreperso

achie

self-e


30/30

y Point out maladaptivebehaviors.

y Instruct in need foradequate rest and

balanced diet.

y Assist in development ofalternative support

system. Encourage

participation in self-help

groups as available.

This helps patientfocus on more

appropriatestrategies.

These facilitate copingstrengths. Inadequate

diet and fatigue can

themselves be

stressors.

Relationships withpersons with common

interests and goals

can be beneficial.

Nursing Care Plans

Nursing Diagnosis &

Interventions

Gulanick,Myers,Klopp,Galan

es,Gradishar, Puzas

np revised

Documents