A. INTR INTROD ODUC UCTI TION ON Psychiatric area is one area of exposure of the nursing students. Our group was lucky enough to be assigned at the psychiatric area at BGHMC (Baguio General Hosp Hospit ital al and and Me Medi dica call Ce Cent nter er). ). The The grou group p had had encou encount nter ered ed seve severa rall comm common on psychiatric disorders like the different types of schizophrenia and bipolar disorders. The group had chosen to study Bipolar Affective Disorder, current episode, manic with with psycho psychotic tic disorder disorder.. The group had chosen chosen this this type type of disord disorder er for us to understand and appreciate this type of psychiatric ailment. Bipolar disorder or manic-depressive disorder which causes mood swings that ranges from the lows of depression to the highs of mania. In some cases, bipolar disord disorder er causes causes sympto symptoms ms of depres depressio sion n and mania at the same same time. time. Bipol Bipolar ar disorder causes serious shifts in mood, energy, thinking and behavior from the highs of mania on one extreme to the lows depression on the other. More than just a fleeting good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or even a year. Unlike ordinary mood swings, the mood changes, bipolar disorder is so intense that it interferes with your ability to function. If the client is under mania, the common signs and symptoms includes feeling that are unusually high, optimistic and very irritable, unrealistic, grandiose belief about about one’s one’s abilit abilities ies or powers, powers, sleepi sleeping ng less less but feelin feeling g extrem extremely ely energe energetic tic,, talkin talking g so rapidl rapidly, y, racing racing though thoughts, ts, jumpin jumping g quickl quickly y from from one idea idea to the next, next, highly distractible, impaired judgement and impulsiveness, acting recklessly without thin thinki king ng abou aboutt the the conse consequ quenc ences es and and last lastly ly in seve severe re case cases, s, delu delusi sion ons s and and hallucinations may appear. If the the clie client nt is under under depr depress essiv ive, e, the the comm common on sign signs s and and symp sympto toms ms are are decreased energy, easy fatigability, lethargic, has diminished activities, insomnia or even hypersomnia, usually lost of interest in pleasurable activities and lastly social withdrawal. B. PATI PATIEN ENT’ T’S S PROFI PROFILE LE Name:
Mr. I.E.R
Age:
56 years old
Birthday:
July 4, 1953
Civil Status:
Married
Address:
Km8 Asin road, Tuba, Benguet
Religion:
Roman Catholic
Nationality:
Filipino
Date of Admission:
June 11, 2010
Time of Admission:
7:35 PM 1
Admitting Diagnosis:
Bipolar
Affective
Disorder,
Current Episode, Manic with Psychotic Disorder C. ASSE ASSESS SSME MENT NT 1. Psychiatric Psychiatric History/Dev History/Developm elopmental ental History History The patient is born via NSVD (normal spontaneous vaginal delivery), no known complications and abortion attempts of the mother. According to the patient he was both breastfed and bottlefed up to 1 ½ years of age. He was also toilet trained by his parents. He further claimed that he was pampered by his parents with love and affection as well as with other things like toys, books and clothing. clothing. Basically, Basically, he had a good childhood childhood experience as claimed. During his school age, he remembered remembered that he does not participate participate in school school activi activitie ties s and seldom seldom mingle mingle with with his classma classmates tes.. He furthe furtherr claimed that he is respectful to elders especially to his parents and gran grandp dpar arent ents. s. Duri During ng his his high high scho school ol year years, s, he expe experi rienc enced ed bein being g involved with fist fights with the bullies. He remembered he was never sepa separa ratted from from his his fam family ily and was able ble to fini finish sh his degre egree e in mechanical engineering. He was married at the age of 36 years old. After how many years, his wife gave birth to a baby boy. They then decided that the husband will go abroad in Saudi Saudi Arabia Arabia and work as a mechanical mechanical Engineer Engineer while his wife is left with the son in the Philippines. After how many years, they decided to switch, the husband was left with the baby and his wife went abroad to Saudi to work as a nurse at a hospital. With this set up of a long distance relationship which is too hard to handle. Being away from your wife and being with your son for several years. His wife has only quality time for them whenever she comes home for vacation. Whenever his wife comes home for a vacation, he is usually very happy. According to the patient, the most traumatic experience he had is the death of his sister. It was during this time that he knew that his sister died to an accident, due to financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very sad because he claimed that he was really close to his sister. For his other siblings, he visits them occasionally and whenever there was a problem with one of the member of the family he and the others would lend their hands and intervene to any problem to resolve it.
2
Admitting Diagnosis:
Bipolar
Affective
Disorder,
Current Episode, Manic with Psychotic Disorder C. ASSE ASSESS SSME MENT NT 1. Psychiatric Psychiatric History/Dev History/Developm elopmental ental History History The patient is born via NSVD (normal spontaneous vaginal delivery), no known complications and abortion attempts of the mother. According to the patient he was both breastfed and bottlefed up to 1 ½ years of age. He was also toilet trained by his parents. He further claimed that he was pampered by his parents with love and affection as well as with other things like toys, books and clothing. clothing. Basically, Basically, he had a good childhood childhood experience as claimed. During his school age, he remembered remembered that he does not participate participate in school school activi activitie ties s and seldom seldom mingle mingle with with his classma classmates tes.. He furthe furtherr claimed that he is respectful to elders especially to his parents and gran grandp dpar arent ents. s. Duri During ng his his high high scho school ol year years, s, he expe experi rienc enced ed bein being g involved with fist fights with the bullies. He remembered he was never sepa separa ratted from from his his fam family ily and was able ble to fini finish sh his degre egree e in mechanical engineering. He was married at the age of 36 years old. After how many years, his wife gave birth to a baby boy. They then decided that the husband will go abroad in Saudi Saudi Arabia Arabia and work as a mechanical mechanical Engineer Engineer while his wife is left with the son in the Philippines. After how many years, they decided to switch, the husband was left with the baby and his wife went abroad to Saudi to work as a nurse at a hospital. With this set up of a long distance relationship which is too hard to handle. Being away from your wife and being with your son for several years. His wife has only quality time for them whenever she comes home for vacation. Whenever his wife comes home for a vacation, he is usually very happy. According to the patient, the most traumatic experience he had is the death of his sister. It was during this time that he knew that his sister died to an accident, due to financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very sad because he claimed that he was really close to his sister. For his other siblings, he visits them occasionally and whenever there was a problem with one of the member of the family he and the others would lend their hands and intervene to any problem to resolve it.
2
He and his neighbor misunderstood each other, but not identified, every now and then they are almost having an argument. The son saw his change of reactions and behaviors 5 days prior to admission like auditory hallucinations, illusions, mood swings, he keeps on digging at their backyard and always saying that “may ginto sa likod ng bahay natin”. Now at his age of 56 years old, he was admitted because of the presence of hallucinations, illusions and delusions. He claimed that he was brought to the hospital because of his hypertension. Often times he sits on his bed or lie down and sleep, he usually don’t mingle with the other patients but feels comfortable when talking to student nurses. 2. Histor History y of of Prese Present nt Illn Illness ess The patient could remember that his mother told him that when he was was sick sick with with chic chicke kenp npox ox and and meas measle les, s, he had had high high feve feverr and and convulsion. Aside from this, patient claimed he was generally healthy as a child. During his school age, he claimed that he was shy. He does not participate in school activities and seldom mingle with his classmates but as he grows up, he further claimed that he feels more comfortable with girls and so he has h as more female friends than boys. At the age of 15, after he graduated from high school, he then have h ave to be separated to his family because he enrolled to one of the schools in Baguio to finish his college degree. It was his first time to be separated from his family and so he felt so sad. During his college years, he learned to be independent and so he was able able to finish finish his chosen chosen field field of mechani mechanica call enginee engineerin ring. g. After After graduating, he decided to work abroad in Saudi to earn his own money. He then met his wife who is a registered nurse in one of the Hospitals in Saudi. They got married and blessed with a son. In order to sustain their needs of the family, he continued to work abroad leaving his family in Zamboanga. They decided that his wife will go abroad also leaving their son with him. With this set up of a long distance relationship which is too hard to handle. Being away from your wife and being with your son for several years. His wife has only quality time for them whenever she come comes s home home for for vaca vacati tion on.. When Whenev ever er his his wife wife come comes s home home for for a vacation, he is usually very happy. According to the patient, the most traumatic experience he had is the death of his sister. It was during this time that he learned that his sister died from an accident, due to financial matters he wasn’t able to attend his sister’s burial. That is the time he feels very sad because he claimed 3
that he was really close to his sister. For his other siblings, he visits them occasionally and whenever there was a problem with one of the member of the family he and the others would lend their hands and intervene to any problem to resolve it. In the case of our patient there was no mental illness in the family. However, he was only diagnosed with hypertension before admission at the Psychiatric Hospital. The time he was firstly observed with manifestations of the disorder the patient was into treasure hunting. He claimed that he met an old woman that was dictating him what to do and where to hunt. He claimed that the old woman manipulated him to do it. Since then, the patient would dig around their backyard and was preoccupied with doing unnecessary things, but the patient wouldn’t forget his position in the family and would do household chores and would act accordingly. He was helpful with doing house chores but noticed that he had lost his social life. His friends were not visiting him anymore and vice versa. Soon after, the patient’s wife came home from Saudi, and around that time he was observed to be normal again, the patient stopped his treasure hunting activities and also claimed that he stopped seeing the old woman. He was observed to be happy during those times. The wife then went back to Saudi and after sometime the patient resumed his usual activities of digging around their house. The patient started to mumble, and would walk around the house to and fro and he would utter incoherent words. Five days prior to admission, the patient felt abnormally good, high, excited, hyperactive and irritable. This was extreme since the patient lost contact with reality and started to believe strange things. He had poor judgment and behaved in harmful ways which was dangerous. This was accompanied by an elevated mood and he had reduced sleep. He had optimistic ideas and plans were expressed. The patient developed symptoms of hallucination and delusion. One day prior to admission, the patient kept on saying S.B, who was the patient’s relative who worked in a mining company. After he went to Balatoc Mines, during the night when his son was watching t.v. the patient came close to him saying, “Sino ka… sino ka?... P.F. (their neighbor whom he always had an argument with). So, the son introduced himself. Afterwards, the patient went to his room shouting over and over again. Out of fear, the son called their relatives and asked help from the nearby police station to get the patient. The patient was seen half naked, praying on the road, kissing the ground and saying that he is the savior. The patient had a bag of stones and books saying he would go home to Zamboanga leaving the treasure to 4
his son. He was held and brought to the institution hence the admission. Hence patient I.R., 56 years old was admitted and diagnosed with bipolar affective disorder, current episode, manic with psychotic symptoms.
3. Mental Status Examination A. APPEARANCE The client appears to be well groomed. Mr. I.R. has a noticeably proper cut hair and is well combed. Mr. I.R. wears clothing appropriately depending on his mood and with the weather. Mr. I.R. refers wearing long sleeves but when it is hot, he wears the usual t-shirt along with his shorts or any available pants he has. For 3 consecutive days of duty, it was observed that he only took a bath on the third day then changed his clothes; the patient is observed to brush his teeth before and after meals. His nails are trimmed and his beard and mustache are neatly shaved. The client appeared as the stated age of 56 years old with visibly white hair and some noticeably wrinkles on his face. B. BEHAVIOR 1. MANNER OF RELATING Mr. I.R. is participative during discussion. He actively and openly answers queries being asked to him by the student nurses. He sometimes cracks jokes that make the conversation lively. He usually prefers to talk with student nurses rather than to his co-patients inside the ward. 2. PSYCHOMOTOR ACTIVITES The patient has a good posture. However, he sometimes slouches during conversation with his legs and arms crossed and sometimes with his hands on his lap, swaying his feet while looking around the room. He usually stay on bed sitting or if not, sleeping. Patient has 5
good posture, gait and station. He was observed to walk straight. He has mild hand tremors observed. 3. SPEECH/LANGUAGE The client talks with normal rate, rhythm and intensity. He speaks clearly and has good articulation of words. He elaborates his answers to questions asked and sometimes, he shares some topics to be discussed. It was also observed that he can easily find the right words to use when lost during conversation. To explain further what are his thoughts. Patient is able to talk in English, Tagalog and Ilokano fluently. 4. RELEVANCE/COHERENCE The client was able to answer relevantly and coherently. He used simple, concrete and easy to understand responses to the topics being discussed during the NPI (Nurse-Patient-Interaction). 5. DEVIATIONS There were no deviation like inventing, rhyming, stammering, clanging of words, repetition of words and speeches in particular questions being asked by the student nurses noted. 6. VOCABULARY The patient uses appropriate terms to use when conversing. He sometimes use terms related to his field of engineering such as the different machineries and gadgets he encountered while he is still studying and working abroad. Patient is able to adjust his choice of words depending on whom he is talking to. He would use simple words to his co-patient while he uses more complex vocabularies to the health care providers. C. MOOD and AFFECT Mr. I.R. stated “okay naman pero minsan nadedepress”. It was observed during the conversation that whenever the discussion deals with his wife finding time visiting him, he feels very happy and is seen smiling. However, when the topic is about the incident where he wasn’t able to visit his sister and dad’s burial, he becomes very sad with teary eyes. D. THINKING During the conversation, Mr. I.R. was able to discuss topics concerning religion, philosophy and history. He was able to discuss recent events of the world and how these are predicted by previous events. He also talks about his work and how was he as an employee when he works abroad. He talks about his family often and mentioned “Yung asawa ko nagwork sa Saudi at may isa akong anak.. Maaga nakapag asawa. May isa na akong apo.” There was no paranoid delusions observed from the client. However the patient was observe to avoid topics which concern on the reasons why he was brought to
6
the hospital. Mr. I.R. is oriented to person, place, time and self. He can identify who brought him to the ward. The patient is able to recall recent and past events in his personal history. He can still recall up to now that he’s 56 years old the memorable experience he had when he was 6 years old which made his parents got mad. He said “May ilog kasi doon malapit sa bahay namin. Naliligo kami ng walang paalam kaya pag-uwi namin, palagi kaming nabubuking kaya napapalo kami”. When the patient was asked to tell the name of one of our costudent nurse that was introduced to him for no longer than 15 minutes, he said “ Si Earl, oo yung mataba. Siya yung una kong nakita nung pagpasok niyo. Malaking tao kasi.”. E. ABSTRACTION When the patient was asked of how did he understand the saying “A hard beginning maketh a good ending.” He responded immediately “ Parang ganito sa situation ko, para akong nakakulong ngayon pero there’s a purpose why I am here however taking that all into consideration, I am positive that this turmoil is to make me and my family stronger than before”. 1. CALCULATION AND CONCENTRATION The patient was able to compute simple mathematical equations as fast as 5 to 10 seconds when asked to answer “9 x 23=___”. He can concentrate even if the ward seems so noisy.
2. INSIGHT When he was asked how can he sees himself as a father to his child, he simply said “ I have been a good father or a parent. In fact not only that, I know I have been a good husband to my wife kasi ginawa ko lahat para mabigyan sila ng magandang buhay sa pamamagitan ng pagtatrabaho ko at pagtitiis ko sa Iran for income out of hard work.”He also claimed “Hypertension talaga problema ko. Hindi naman ako baliw. Wala akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita nung iba kong kasamahan dito”.The patient mentioned
also
“
Magbabakasyon
muna
ako
sa
Zamboanga
pagnakalabas ako dito para makapagpahinga na din. Kasama ko ang asawa kong pupunta siguro.” 7
3. JUDGMENT The client mentioned along with the discussion that he had some fight with his neighbor and was asked of what he will do when he sees his neighbor again and he said “Makikipag ayos na ako. Siguro nga talagang kailangan na ng peace-of-mind kaya makipag=ayos na”. F. SUPEREGO FUNCTIONING/IMPULSE CONTROL The client stated that “Noong hindi ko natulungan yung ate ko financially at noong hindi ako nakapunta nung burol nya” when he was asked what he or makes him guilty or what he regrets the most. G. SELF- CONCEPT The patient has low self-esteem as he is shy and he doesn’t mingle or talk with the other patients in the ward. When conversing with him he often focuses on his positive behavior like being a good husband to his wife and father to his son, which indicates that he is trying to elevate his self-esteem. H. PHYSICAL COMPLAINTS/PROBLEMS The client doesn’t have any physical deformities. He is slow when walking because of aging. He has tremors and claimed that “Ganito ‘to kasi side effect ng gamot”, which indicates a circulatory problem because of HPN.
8
D. DIAGNOSTIC EXAMINATION
Date of Procedure
Diagnostic Procedure
Description
Results
Normal Values
Significance
June 12, 2010
Urinalysis
This test detects ion concentration of the urine. Small amounts of protein or ketoacidosis tend to elevate results of the specific gravity. Specific gravity is an expression of the weight of a substance relative to the weight of an equal volume of water.
Color: yellow
Normal
Transparency: Slightly Turbid
Normal
The specific gravity of your urine is measured by using a urinometer. Knowing the specific gravity of your urine is very important because the number indicates whether you are hydrated or dehydrated.
Normal
Reaction/pH: 6.0
Concentrated urine
Specific Gravity: 1.020
Normal
Protein: Neg
Normal
WBC: None
Normal
Epithelial Cells: Rare
Normal
Bacteria: None
Amorphous urates/PO4: Occasional
There is a presence of amorphous urates due to prolong refrigeration.
9
Date of Procedure
June 17, 2010
Diagnostic Procedure
Description
CBC (Complete The CBC is used as a Blood Count) broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood.
Results
Normal Values
Significance
RBC - 4.32 x 1012/L
4.6 – 6.2 x 10 12/L
WBC -10.4 x 10 9/L
4.5 – 11.0 x 10 9/L
Lymph # -2.7 x 10 9/L
0.8 – 4.0 x 10 9/L
Mid # -0.9 x 10 9/L
0.1– 0.9 x 109/L
The significance of this laboratory procedure is to mainly includes the care and treatment of patients with conditions that will result in increases or decreases in the cell populations
Gran # -6.8 x 10 9/L
2.0 – 7.0 x 10 9/L
Lymph % -26.2 %
20.0 – 40.0 %
Mid % -8.2%
3.0 – 9.0 %
Gran % - 65.65
50.0 – 70.0 %
Hgb - 141 g/L
135 -180 g/L
HCT - 0.433/L
0.4 – 0.54/L
MCV - 99.8/L
78.0 - 100.0/L
MCH -32.4 pg
27.0 – 31.0 pg
MCHC -325 g/L
320 – 360 g/L
RDW-CV - 13.1 %
11.5 – 14.5 %
10
RDW-SD - 48.6/L
35 – 56/L
PLT - adequate MPV - 6.8/L
7.0 – 11.0/L
PDW - 15.5/L
15.0 – 17.0/L
Date of Procedure
June 17, 2010
Diagnostic Procedure
Description
CBC (Complete The CBC is used as a Blood Count) broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood.
Results
Normal Values
Significance
RBC - 4.32 x 1012/L
4.6 – 6.2 x 10 12/L
WBC -10.4 x 10 9/L
4.5 – 11.0 x 10 9/L
Lymph # -2.7 x 10 9/L
0.8 – 4.0 x 10 9/L
Mid # -0.9 x 10 9/L
0.1– 0.9 x 109/L
The significance of this laboratory procedure is to mainly includes the care and treatment of patients with conditions that will result in increases or decreases in the cell populations
Gran # -6.8 x 10 9/L
2.0 – 7.0 x 10 9/L
Lymph % -26.2 %
20.0 – 40.0 %
Mid % -8.2%
3.0 – 9.0 %
Gran % - 65.65
50.0 – 70.0 %
Hgb - 141 g/L
135 -180 g/L
HCT - 0.433/L
0.4 – 0.54/L
MCV - 99.8/L
78.0 - 100.0/L
MCH -32.4 pg
27.0 – 31.0 pg
MCHC -325 g/L
320 – 360 g/L
RDW-CV - 13.1 %
11.5 – 14.5 %
10
RDW-SD - 48.6/L
35 – 56/L
PLT - adequate MPV - 6.8/L
7.0 – 11.0/L
PDW - 15.5/L
15.0 – 17.0/L
PCT - 0.184 %
0.108 – 0.282 %
11
E. PSYCHOPATHOLOGY 1. Biological Cause A. Neurotransmitter Alteration
RDW-SD - 48.6/L
35 – 56/L
PLT - adequate MPV - 6.8/L
7.0 – 11.0/L
PDW - 15.5/L
15.0 – 17.0/L
PCT - 0.184 %
0.108 – 0.282 %
11
E. PSYCHOPATHOLOGY 1. Biological Cause A. Neurotransmitter Alteration A.1 Increase Dopamine - Overproduction of dopamine causes the nerve circuits to misfire and create a split state in the mind where delusions and hallucinations make the reality of the outside world easier to accept A.2 Increase Serotonin level - An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder. Because he has the three signs of mania which are Auditory Hallucinations, delusions and paranoia A.3 Decrease Serotonin Level - A decrease in serotonin levels indicates depression. He has the symptoms of depression like social withdrawal, low selfesteem and persistent sadness B. Genetic Predisposition B.1 Being Shy - He has the presence of the type A personality, which is inherently acquired thus he has poor IPR to others 2. Psychosocial Causes A. Development of Mistrust - It is according to Freud’s Psycho-social theory. Presented by poor IPR to other people, unable to express feelings, lack of close
E. PSYCHOPATHOLOGY 1. Biological Cause A. Neurotransmitter Alteration A.1 Increase Dopamine - Overproduction of dopamine causes the nerve circuits to misfire and create a split state in the mind where delusions and hallucinations make the reality of the outside world easier to accept A.2 Increase Serotonin level - An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder. Because he has the three signs of mania which are Auditory Hallucinations, delusions and paranoia A.3 Decrease Serotonin Level - A decrease in serotonin levels indicates depression. He has the symptoms of depression like social withdrawal, low selfesteem and persistent sadness B. Genetic Predisposition B.1 Being Shy - He has the presence of the type A personality, which is inherently acquired thus he has poor IPR to others 2. Psychosocial Causes A. Development of Mistrust - It is according to Freud’s Psycho-social theory. Presented by poor IPR to other people, unable to express feelings, lack of close friends, isolates self, social withdrawal B. Cultural Norms -
Because they have a close-knit family
C. Traumatic Experience C.1 Separation from family members - Being alone and independent in an area that is unfamiliar C.2 Death of his Sister - As presented by Long term depression C.3 Living alone for several years - As manifested by anxiety and fear D. Use of Defense Mechanism -
Ineffective use of Denial as manifested by unrealistic perception
of the situation
12
PSYCHODYNAMICS Neurotransmitter Alteration
Psychosocial Causes Genetic
Dopami Over production of dopamine causes nerve circuits to misfire and create a split Auditory hallucinatio
Serotoni
Type A Increas
Paranoia
Close-knit family
-Unable to express feelings Manic
Depressive
Signs and Symptoms:
-Lack of close friends -Isolates self
Signs and Symptoms:
-Social withdrawal
-Insomnia -Persistent sadness -Social withdrawal -Low selfesteem -Difficulty Concentratin
Traumatic Experience
Separation from family
Chronic Low Self-
Bipolar Affective Disorder, Current Episode, Manic with Psychotic Disorder
Risk for in ur Poor compliance to treatment regimen
Cultural norms
Poor IPR to other people
Decrea
-Agitation Hyperactivity -Racing Thoughts -Delusions of Grandeur -Illusions -
Delusion
Development vs. Mistrust
Being shy
Possible separation to wife
Death of his sister
Living alone for several
Anxiety
Use of defense mechanism
Long term depression
Denial
Stress
Ineffective
Activation of the SNS (fight or flight response)
Unrealistic perception of the situation
Blood Pressure, pulse rate, respiration
Causing disturbed visual field and postural imbalance
Hypertensio
Altered cardiovascu lar status
Risk for relapsed episode 13
F. DRUG STUDY
Generic name
Classificatio n
Dosage Start and Completion of Medication
Calcium channel blocker
Dosage: 10 mg 1 tab OD
Antianginal drug
Date started: 06/17/10
Trade name
Amlodipine besylate
Norvasc
Antihyperten sive
Mechanism of Action
Indication
Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. coronary artery disease
>Essential hypertension, or in combination with other agents
Side Effects
Nursing Consideration
CNS: dizziness, lightheadedness, headache, fatigue CV: peripheral edema, arrhythmias DERMATOL OGIC: Flush, rash GI: nausea, abdominal discomfort.
>Monitor the patient’s BP, cardiac rhythm, and output while adjusting drug to therapeutic dose. >instruct client to swallow the tablet whole with or without food as directed by the physician. >Instruct client to take with meals if stomach upset occurs. > tell the client to report irregular heartbeat, shortness of breath, swelling of hands and feet, pronounced dizziness or constipation.
14
Generic name
Classificatio n
Trade name
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Side Effects
Nursing Consideration
15
Clonidine Antihyperten hydrochloride sive Catapres
Dosage: 75 mg. 1 tab SL fo BP ≥ 140/90 Date started: 06/14/10
Stimulates CNS alpha2 adrenergic receptors, inhibits sympathetic cardioaccelerator and
>For hypertension
CNS: drowsiness, sedation, dizziness CV: CHF, orthostatic hypotension, tachycardia,
>monitor BP carefully, when discontinuing clonidine, hypertension usually returns within 48 hours. >Take the drug exactly as prescribed. The drug should be put under the
Generic name
Classificatio n
Trade name
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Side Effects
Nursing Consideration
15
Clonidine Antihyperten hydrochloride sive Catapres
Dosage: 75 mg. 1 tab SL fo BP ≥ 140/90 Date started: 06/14/10
Generic name
Classificatio n
Dosage Start and Completion
Stimulates CNS alpha2 adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centres, and decreases sympathetic outflow from CNS.
>For hypertension
Mechanism of Action
Indication
CNS: drowsiness, sedation, dizziness CV: CHF, orthostatic hypotension, tachycardia, palpitations GI: dry mouth, constipation, nausea GU: impotence, decreased sexual activity, diminished libido
>monitor BP carefully, when discontinuing clonidine, hypertension usually returns within 48 hours. >Take the drug exactly as prescribed. The drug should be put under the tongue. >Do not discontinue drug unless so instructed. > tell the patient that discontinuing abruptly, life threatening adverse effects may occur.
Side Effects
Nursing Consideration 16
Trade name
Lithium carbonate
Carbolith
of Medication
Antimanic drug
Dosage: 450 mg 1 tab BID Date started: 06/12/10
Alters sodium transport in nerve and muscle cells, inhibits release of norepinephrine and dopamine,
Treatment of manic episodes of manicdepressive illness.
CNS: lethargy, slurre d speech, muscle weakness
>Give drug with food or milk after meals. >Monitor clinical status closely >take this drug exactly as prescribed, after
Clonidine Antihyperten hydrochloride sive Catapres
Dosage: 75 mg. 1 tab SL fo BP ≥ 140/90 Date started: 06/14/10
Generic name
Classificatio n
Dosage Start and Completion
Stimulates CNS alpha2 adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centres, and decreases sympathetic outflow from CNS.
>For hypertension
Mechanism of Action
Indication
CNS: drowsiness, sedation, dizziness CV: CHF, orthostatic hypotension, tachycardia, palpitations GI: dry mouth, constipation, nausea GU: impotence, decreased sexual activity, diminished libido
>monitor BP carefully, when discontinuing clonidine, hypertension usually returns within 48 hours. >Take the drug exactly as prescribed. The drug should be put under the tongue. >Do not discontinue drug unless so instructed. > tell the patient that discontinuing abruptly, life threatening adverse effects may occur.
Side Effects
Nursing Consideration 16
Trade name
Lithium carbonate
of Medication
Antimanic drug
Dosage: 450 mg 1 tab BID Date started: 06/12/10
Carbolith
Alters sodium Treatment of transport in nerve manic and muscle cells, episodes of inhibits release of manicnorepinephrine depressive and dopamine, illness. but not serotonin from stimulated neurons, slightly increases intraneural stone of cathecolamines; decrease intraneuronal content of second messengers and may the by selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.
CNS: lethargy, slurre d speech, muscle weakness GI: nausea, vomiting, diarrhea GU: pyloria
>Give drug with food or milk after meals. >Monitor clinical status closely >take this drug exactly as prescribed, after meals or with food or ,milk >Instruct client to open mouth and lift tongue to check for the drugs. >tell the patient to eat a normal diet with a normal salt intake, maintain adequate fluid intake.
17
Generic name
Classificatio n
Trade name
Haloperidol
ti
hoti
Dosage Start and Completion of Medication
Mechanism of Action
Haloperidol
Indication
Side Effects
Nursing Consideration
>Take the drug with
Trade name
Lithium carbonate
of Medication
Antimanic drug
Dosage: 450 mg 1 tab BID Date started: 06/12/10
Carbolith
Alters sodium Treatment of transport in nerve manic and muscle cells, episodes of inhibits release of manicnorepinephrine depressive and dopamine, illness. but not serotonin from stimulated neurons, slightly increases intraneural stone of cathecolamines; decrease intraneuronal content of second messengers and may the by selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.
CNS: lethargy, slurre d speech, muscle weakness GI: nausea, vomiting, diarrhea GU: pyloria
>Give drug with food or milk after meals. >Monitor clinical status closely >take this drug exactly as prescribed, after meals or with food or ,milk >Instruct client to open mouth and lift tongue to check for the drugs. >tell the patient to eat a normal diet with a normal salt intake, maintain adequate fluid intake.
17
Generic name
Classificatio n
Trade name
Haloperidol haldol
antipsychotic
Dosage Start and Completion of Medication Dosage: 10 mg deep IMx 3 doses PRN for severe psychotic agitation.
Date started: 06/11/2010
Mechanism of Action
Indication
Side Effects
Nursing Consideration
Haloperidol interferes with the effects of neurotransmitter s in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another. It blocks receptors for the neurotransmitter s (specifically the dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not "activated" by
Management of manifestation of psychotic disorders.
CNS: drowsiness, insomnia, headache autonomic: drymouth, salivation, nasal congestion CV: hypotension hematologic : eosinophilia, leukopenia
>Take the drug with food or exactly as prescribed. >Do not dilute this with coffee, tea, colas or apple juice - the medication may lose effectiveness. >Do not stop taking this drug suddenly without consulting your doctor. >Instruct client to open mouth and lift tongue to check for the drugs. >Instruct client to Avoid engaging in other dangerous activities. If dizziness or drowsiness or vision changes occurs.
18
the neurotransmitter s released by other nerves
Generic name
Classificatio n
Trade name
Haloperidol
antipsychotic
haldol
Dosage Start and Completion of Medication Dosage: 10 mg deep IMx 3 doses PRN for severe psychotic agitation.
Date started: 06/11/2010
Mechanism of Action
Indication
Side Effects
Nursing Consideration
Haloperidol interferes with the effects of neurotransmitter s in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another. It blocks receptors for the neurotransmitter s (specifically the dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not "activated" by
Management of manifestation of psychotic disorders.
CNS: drowsiness, insomnia, headache autonomic: drymouth, salivation, nasal congestion CV: hypotension hematologic : eosinophilia, leukopenia
>Take the drug with food or exactly as prescribed. >Do not dilute this with coffee, tea, colas or apple juice - the medication may lose effectiveness. >Do not stop taking this drug suddenly without consulting your doctor. >Instruct client to open mouth and lift tongue to check for the drugs. >Instruct client to Avoid engaging in other dangerous activities. If dizziness or drowsiness or vision changes occurs.
18
the neurotransmitter s released by other nerves
Generic name
Classificati on
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Side Effects
Nursing Consideration
Antihistamin e Antiparkinso nian
Dosage: 50 mg. IM q 1 hr. x 3 doses PRN for severe psychotic agitation with BP precaution
Competitively blocks the effects of histamine at H1-receptor sites, Diphenhydramine also blocks the action of acetylcholine (anticholinergic effect) and is used as a sedative because it causes drowsiness
Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly tolerant of the more potent agens, for milder form of disorders in other age groups, and in combination of
CNS: drowsiness, sedation, dizziness CV: hypotension, palpitation, bradycardia GI: epigastric distress, anorexia, GU: urinary frequency, dysuria thrombocytope nia
>Administer with food if GI upset occurs. >Monitor patient’s response. >take as prescribed, avoid excessive dosage >Instruct client to open mouth and lift tongue to check for the drugs. >tell the client to report difficulty of breathing, tremors, unusual bleeding or brusing, irregular
Trade name
diphenhydra mine Benadryl
Date started: 06/11/10
19
centrally Hepatic: acting hemolytic anticholinergic anemia antiparkinsonia n drugs.
heart beat.
the neurotransmitter s released by other nerves
Generic name
Classificati on
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Side Effects
Nursing Consideration
Antihistamin e Antiparkinso nian
Dosage: 50 mg. IM q 1 hr. x 3 doses PRN for severe psychotic agitation with BP precaution
Competitively blocks the effects of histamine at H1-receptor sites, Diphenhydramine also blocks the action of acetylcholine (anticholinergic effect) and is used as a sedative because it causes drowsiness
Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly tolerant of the more potent agens, for milder form of disorders in other age groups, and in combination of
CNS: drowsiness, sedation, dizziness CV: hypotension, palpitation, bradycardia GI: epigastric distress, anorexia, GU: urinary frequency, dysuria thrombocytope nia
>Administer with food if GI upset occurs. >Monitor patient’s response. >take as prescribed, avoid excessive dosage >Instruct client to open mouth and lift tongue to check for the drugs. >tell the client to report difficulty of breathing, tremors, unusual bleeding or brusing, irregular
Trade name
diphenhydra mine Benadryl
Date started: 06/11/10
19
centrally Hepatic: acting hemolytic anticholinergic anemia antiparkinsonia n drugs.
Generic name Trade name
Chlorpromazi ne Thorazine
Classificati on
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Antipsychoti Dosage: cs 200 mg. ½ tab AM; 1 tab in HS
Block dopamine receptors in the brain; also alter dopamine release and turnover.
Management of manifestation of psychotic disorders; control of manic phase of manic depressive illness.
Date Started: 06/12/10
Side Effects
CNS: neuroleptic malignant syndrome, sedation, CV: hypotension EENT: blurred vision, GI: constipation, dry mouth, anorexia, GU: urinary retention
heart beat.
Nursing Consideration
>Assess mental status prior to and periodically during therapy. >Monitor BP and pulse prior to and frequently during the period of dosage adjustment. >Observe patient carefully when administering medication. >Instruct client to open mouth and lift tongue to check for 20
Hematologic: leukopenia
the drugs. >Advice patient to take medication as missed doses as soon as remembered, witih remaining doses evenly spaced throughout the day.
centrally Hepatic: acting hemolytic anticholinergic anemia antiparkinsonia n drugs.
Generic name
Classificati on
Dosage Start and Completion of Medication
Mechanism of Action
Indication
Antipsychoti Dosage: cs 200 mg. ½ tab AM; 1 tab in HS
Block dopamine receptors in the brain; also alter dopamine release and turnover.
Management of manifestation of psychotic disorders; control of manic phase of manic depressive illness.
Trade name
Chlorpromazi ne Thorazine
Date Started: 06/12/10
Side Effects
CNS: neuroleptic malignant syndrome, sedation, CV: hypotension EENT: blurred vision, GI: constipation, dry mouth, anorexia, GU: urinary retention
heart beat.
Nursing Consideration
>Assess mental status prior to and periodically during therapy. >Monitor BP and pulse prior to and frequently during the period of dosage adjustment. >Observe patient carefully when administering medication. >Instruct client to open mouth and lift tongue to check for 20
Hematologic: leukopenia
Generic name Trade name
Biperiden
Classificatio n
Dosage Start and Completio n of Medication
antiparkinson Dosage: ian 2 mg. 1 tab OD
akineton Date started: 06/12/10
Mechanism of Action
Anticholinergic activity in the CNS that is believed to helpnormalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmitter in the basal ganglia of the brain of a parkinsonism
the drugs. >Advice patient to take medication as missed doses as soon as remembered, witih remaining doses evenly spaced throughout the day.
Indication
Side Effects
Nursing Consideration
Adjunct in the therapy of parkinsonism (post encephalitic, arterioschleroti c, and idiopathic types)
CNS: disorientation, confusion, memory loss, hallucination CV: tachycardia, palpitations, hypotension Dermatologic : rash, urticaria GI: dry mouth, constipation, dilatation of
>Give with meals if GI upset occurs, give before meals for clients who have dry mouth, give after meals if drooling or vomiting occurs. >Take the drug as prescribed. >Instruct client to open mouth and lift tongue to check for the drugs. > tell patient to report 21
patient. Reduces severity of rigidity, and to lesser extent, akinesia and tremor characterizing parkinsonism.
colon
difficult or painful urination; constipation, rapid pounding of the heart, confusion, eye pain or rash.
Hematologic: leukopenia
Generic name
Classificatio n
Trade name
Biperiden
Dosage Start and Completio n of Medication
antiparkinson Dosage: ian 2 mg. 1 tab OD
akineton Date started: 06/12/10
Mechanism of Action
Anticholinergic activity in the CNS that is believed to helpnormalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmitter in the basal ganglia of the brain of a parkinsonism
the drugs. >Advice patient to take medication as missed doses as soon as remembered, witih remaining doses evenly spaced throughout the day.
Indication
Side Effects
Nursing Consideration
Adjunct in the therapy of parkinsonism (post encephalitic, arterioschleroti c, and idiopathic types)
CNS: disorientation, confusion, memory loss, hallucination CV: tachycardia, palpitations, hypotension Dermatologic : rash, urticaria GI: dry mouth, constipation, dilatation of
>Give with meals if GI upset occurs, give before meals for clients who have dry mouth, give after meals if drooling or vomiting occurs. >Take the drug as prescribed. >Instruct client to open mouth and lift tongue to check for the drugs. > tell patient to report 21
patient. Reduces severity of rigidity, and to lesser extent, akinesia and tremor characterizing parkinsonism.
colon
difficult or painful urination; constipation, rapid pounding of the heart, confusion, eye pain or rash.
22
G. PRIORITIZATION RANKING
NURSING DIAGNOSIS/ PROBLEMS
JUSTIFICATION
patient. Reduces severity of rigidity, and to lesser extent, akinesia and tremor characterizing parkinsonism.
colon
difficult or painful urination; constipation, rapid pounding of the heart, confusion, eye pain or rash.
22
G. PRIORITIZATION RANKING
1
2
NURSING DIAGNOSIS/ PROBLEMS
Altered cardiovascular status related to increase pressure secondary to Hypertension
Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about
JUSTIFICATION
Airway, breathing and circulation concept states that circulation should always be the third to be assessed. And if the heart doesn’t work normally, the other systems and their functions will be affected. The aorta is the largest artery of the body that extends from the left ventricle of the heart to begin the distribution of oxygenated blood throughout the rest of the body, narrowing and clogging of aorta brought about by fatty deposits causes a decrease in the blood flow from the left ventricle into the systemic circulation. This obstruction creates a resistance to ejection and increased pressure in the left ventricle. We ranked this as our second priority because People with chronic low self esteem issues often spend more time worrying about the future, or dwelling on mistakes that they've made in the past, that they fail to enjoy the here and now
G. PRIORITIZATION RANKING
1
2
NURSING DIAGNOSIS/ PROBLEMS
Altered cardiovascular status related to increase pressure secondary to Hypertension
Chronic low self-esteem related to impaired cognitive self-appraisal AEB negative feedback about self
Ineffective denial related to inability to tolerate the consequences of known disorder 3
JUSTIFICATION
Airway, breathing and circulation concept states that circulation should always be the third to be assessed. And if the heart doesn’t work normally, the other systems and their functions will be affected. The aorta is the largest artery of the body that extends from the left ventricle of the heart to begin the distribution of oxygenated blood throughout the rest of the body, narrowing and clogging of aorta brought about by fatty deposits causes a decrease in the blood flow from the left ventricle into the systemic circulation. This obstruction creates a resistance to ejection and increased pressure in the left ventricle. We ranked this as our second priority because People with chronic low self esteem issues often spend more time worrying about the future, or dwelling on mistakes that they've made in the past, that they fail to enjoy the here and now moments in life. Without the self esteem to believe they can accomplish something new, fear keeps the sufferer from asking for that promotion; going on a date with the person they're attracted to; or even getting on that roller coaster with their kids. For most persons, everyday life includes its share of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. Socio-cultural and religious factors may influence how people view and handle their
23
problems. Vulnerable populations such as elderly patients, those in adverse socioeconomic situations, or those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors.
4
5
Risk for injury related to imbalanced between oxygen supply and demand secondary to hypertension
Risk for relapsed episode maybe R/T poor medical treatment regimen compliance
Risk for injury is one of the most common complications of hypertension that is why it is the prioritized potential problem. Patient’s having hypertension are prone to injury because of the imbalance in their oxygen supply and demand causing disturbed visual field and postural imbalance. If this potential problem is not given immediate attention, this may cause a more serious problem to the patient.
We ranked this as the least priority because the chances of having relapse episode are about 40% is needs are not satisfied, majority of psychiatric clients are r/t poor compliance to medical treatment
24
H. NURSING CARE PLAN NCP ACTUAL #1: ALTERED CARDIOVASCULAR STATUS R/T INCREASE PRESSURE SECONDARY TO HYPERTENSION ASSESSMENT
EXPLANATION OF THE PROBLEM
S>” Problema ko tong BP ko, tumataas” Bp150/100
Patient has a history of hypertension. During admission until the third day patient has a fluctuating BP of 130/100 to 150/100, this was caused by over excitement when his wife came home from Saudi and stress that causes sympathetic nervous system (that stimulates the fifgt or flight response) over activity increasing hearts contractility over stress.
O> Fluctuating BP of 140/100 to 150/100 >Feeling of dizziness like when going to the comfort room >Increase respiratory rate >Fast breathing A> Altered cardiovascular status related to increase pressure secondary to Hypertension
Source: Brunner and Suddarth’s MedicalSurgical Nursing 7 th edition
GOALS AND OBJECTIVES
NURSING INTERVENTION
STO: After 1 hour of Dx: >Monitored vital signs especially BP health teaching, >Assessed contributory patient will be able to factors of increase BP demonstrate understanding of Tx: >Assisted in getting up techniques and ways to slowly from bed to bedside prevent further or from supine to moderate high back rest increase of blood >Assisted in going to the pressure like: comfort room or using the commode if necessary a. Waking up >Promoted adequate rest slowly on bed by decreasing stimuli, and resting providing quiet before walking environment and b. Proper Deep scheduling activities breathing Edx: >Instructed to report exercises shortness of breath, chest pain or any discomfort >Emphasized importance of diet low fat, low sodium LTO: After 3 days of >Reiterated religious taking of medication nursing intervention, >Encouraged rest periods the Blood pressure will as necessary be maintained at 130/90 from 150/100
RATIONALE
EVALUATION
>Note response to activities >To know the appropriate intervention >Patient might be getting up of bed in the wrong way which may add up in the increase BP
STO: Goal met, patient was able to demonstrate understanding and techniques to prevent increase of BP
>To provide safety >To maximize sleep periods that provide good energy source >Immediate interventions will be done
LTO: Goal met, patient’s Bp was maintained at 130/90
>To maintain normal BP >To help regulate BP >To prevent sudden increase of BP 25
NCP ACTUAL #2: CHRONIC LOW SELF-ESTEEM R/T IMPAIRED COGNITIVE SELF-APPRAISAL AEB NEGATIVE FEEDBACK ABOUT SELF ASSESSMENT S>“ang asawa ko ang nagtratrabaho para sa min, ako pa man din ang lalaki wala akong magawa” O> Feels guilty and shame when talking about his wife who works for them >Noted attitude of shyness > Unable to communicate with this copatient > Took a bath on the third day only A> Chronic low self-esteem related to impaired cognitive self-
EXPLANATION OF THE PROBLEM Mr. ICI wife is a nurse working in Saudi. She is the one who’s working for their family, taking charge for all their expenses, providing support for their family and taking already the seat as the bread winner of their family. Mr. ICI felt so bad with that because he should be the one who’s doing all of that stuff. He felt shame and guilty to his present situation. To compensate to his shortcomings he made use himself by doing household chores and becoming responsible in taking care of his son but these were not enough to show that he is useful and not enough to show his worth as father. All of the things that he did were in turn inadequate for him which led him to have a chronic low self-esteem.
GOALS AND OBJECTIVES LTO: After 3 days of nursing interventions, the client will be able to verbalize understanding of individual’s role in the society regardless of their gender
INTERVENTION
PDx > Established
RATIONALE
Rapport
>Assessed presence of negative attitude and or self talk
STO: After 8 hours of appropriate nursing interventions, the client will be able to increase > Assessed existing self-esteem through: strengths and coping abilities, and provide a. Giving positive opportunities for feedback their expression and recognition b. Focusing topics such as on the client’s >Noted accomplishments in life non-verbal behavior c. Reinforcing the >Used personal strengths and positive positive perceptions messages that the client identifies rather than
EVALUATION
Individuals with low LTO: Goal met if self-esteem are The client is able reluctant to discuss to verbalize true feelings understanding of individual’s role in the Re-enforcement of society regardless of communicating their gender and interacting with others could stimulate to enhance selfesteem STO: Goal met
Incongruence’s between verbal/nonverbal communications require clarification. To assist client to develop internal sense of selfesteem
The client was able to increase selfesteem through giving positive feedback, was able to appreciate his accomplishments in life and was able to identify his strengths and positive perceptions
Supporting a 26
appraisal AEB negative feedback about self
Source:
www.medscape.com/viewpro gram
praise.
client’s beliefs and self-rejection and helping them cope can affect selfesteem
Tx>Maintained therapeutic communication > Rendered positive feedback
To facilitate trust during interaction
NCP ACTUAL #2: CHRONIC LOW SELF-ESTEEM R/T IMPAIRED COGNITIVE SELF-APPRAISAL AEB NEGATIVE FEEDBACK ABOUT SELF ASSESSMENT S>“ang asawa ko ang nagtratrabaho para sa min, ako pa man din ang lalaki wala akong magawa” O> Feels guilty and shame when talking about his wife who works for them >Noted attitude of shyness > Unable to communicate with this copatient > Took a bath on the third day only A> Chronic low self-esteem related to impaired cognitive self-
EXPLANATION OF THE PROBLEM Mr. ICI wife is a nurse working in Saudi. She is the one who’s working for their family, taking charge for all their expenses, providing support for their family and taking already the seat as the bread winner of their family. Mr. ICI felt so bad with that because he should be the one who’s doing all of that stuff. He felt shame and guilty to his present situation. To compensate to his shortcomings he made use himself by doing household chores and becoming responsible in taking care of his son but these were not enough to show that he is useful and not enough to show his worth as father. All of the things that he did were in turn inadequate for him which led him to have a chronic low self-esteem.
GOALS AND OBJECTIVES LTO: After 3 days of nursing interventions, the client will be able to verbalize understanding of individual’s role in the society regardless of their gender
INTERVENTION
PDx > Established
RATIONALE
Rapport
>Assessed presence of negative attitude and or self talk
STO: After 8 hours of appropriate nursing interventions, the client will be able to increase > Assessed existing self-esteem through: strengths and coping abilities, and provide a. Giving positive opportunities for feedback their expression and recognition b. Focusing topics such as on the client’s >Noted accomplishments in life non-verbal behavior c. Reinforcing the >Used personal strengths and positive positive perceptions messages that the client identifies rather than
EVALUATION
Individuals with low LTO: Goal met if self-esteem are The client is able reluctant to discuss to verbalize true feelings understanding of individual’s role in the Re-enforcement of society regardless of communicating their gender and interacting with others could stimulate to enhance selfesteem STO: Goal met
Incongruence’s between verbal/nonverbal communications require clarification. To assist client to develop internal sense of selfesteem
The client was able to increase selfesteem through giving positive feedback, was able to appreciate his accomplishments in life and was able to identify his strengths and positive perceptions
Supporting a 26
appraisal AEB negative feedback about self
Source:
www.medscape.com/viewpro gram
praise.
client’s beliefs and self-rejection and helping them cope can affect selfesteem
Tx>Maintained therapeutic communication > Rendered positive feedback
To facilitate trust during interaction
>Focused on accomplishments
To increase selfesteem
To lift self-esteem
Positive feedback from group members will increase selfesteem
Edx> Encouraged participation in group activities. Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication >Encouraged client's attempts to communicate. If verbalizations are not understandable, express to client
The ability to communicate effectively with 27
what you think he or she intended to say. It may be necessary to reorient client frequently
>Reinforced the
others may enhance selfesteem
appraisal AEB negative feedback about self
Source:
www.medscape.com/viewpro gram
praise.
client’s beliefs and self-rejection and helping them cope can affect selfesteem
Tx>Maintained therapeutic communication > Rendered positive feedback
To facilitate trust during interaction
>Focused on accomplishments
To increase selfesteem
To lift self-esteem
Positive feedback from group members will increase selfesteem
Edx> Encouraged participation in group activities. Caregiver may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication >Encouraged client's attempts to communicate. If verbalizations are not understandable, express to client
The ability to communicate effectively with 27
what you think he or she intended to say. It may be necessary to reorient client frequently
>Reinforced the personal strengths and positive perceptions that the client identifies.
others may enhance selfesteem
Clients with low self-esteem need to have their existence and value confirmed
Give reinforcement for progress noted.
>Gave reinforcement for progress noted.
28
what you think he or she intended to say. It may be necessary to reorient client frequently
>Reinforced the personal strengths and positive perceptions that the client identifies.
others may enhance selfesteem
Clients with low self-esteem need to have their existence and value confirmed
Give reinforcement for progress noted.
>Gave reinforcement for progress noted.
28
29
ASSE
NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER EXPLANATION OF THE GOALS AND INTERVENTIONS RATIONALE PROBLEM OBJECTIVES
EXPECTED OUTCOME
S>” Hypertension P/Dx> Observed > Shows if the patient STO: NCP POTENTIALOne #1:cause RISK of FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLYresponses AND DEMAND could SECONDARY HYPERTENSION bipolar disorder is STO: naman talaga ang behavioral interactTO and Goal met if the stressful life events these are After 1-2 hours of interested to patient was able problema ko. thought to be the main element in appropriate nursing therapeutic regimen to feelings Hindi ako baliw. the development of bipolar intervention the congruent with Wala naman patient will verbalize >Assessed ability to behavior. disorder. In our patients case one akong nakikita o feelings congruent respond or interpret > To explore hidden factor that could be seen is the nakakausap o with behavior. questions. thoughts and feelings loss of his job making his wife naririnig na gaya that the patient might LTO: work for him and one more thing ng naririnig at LTO: After 2-3 days not show through his Goal met if is that he is left alone while his nakikita ng ibang
of appropriate
facial expressions.
patient meet
29
ASSE
NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER EXPLANATION OF THE GOALS AND INTERVENTIONS RATIONALE PROBLEM OBJECTIVES
EXPECTED OUTCOME
S>” Hypertension P/Dx> Observed > Shows if the patient STO: NCP POTENTIALOne #1:cause RISK of FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLYresponses AND DEMAND could SECONDARY HYPERTENSION bipolar disorder is STO: naman talaga ang behavioral interactTO and Goal met if the stressful life events these are After 1-2 hours of interested to patient was able problema ko. thought to be the main element in appropriate nursing therapeutic regimen to feelings Hindi ako baliw. the development of bipolar intervention the congruent with Wala naman patient will verbalize >Assessed ability to behavior. disorder. In our patients case one akong nakikita o feelings congruent respond or interpret > To explore hidden factor that could be seen is the nakakausap o with behavior. questions. thoughts and feelings loss of his job making his wife naririnig na gaya that the patient might LTO: work for him and one more thing ng naririnig at LTO: After 2-3 days not show through his Goal met if is that he is left alone while his nakikita ng ibang of appropriate facial expressions. patient meet wife is abroad. kasamahan ko nursing interventions > Assessed triggering > knowing the trigger psychological dito.” the patient will meet factor that may stop factors could help you needs as A symptom of bipolar that your client from talking determine what to do evidence by contributes for the patient to deny psychological needs as evidence by to you. if the patient shows. appropriate his known illness is exaggerated appropriate > Client may expression of O> Does not self-esteem. expression of Tx> Minimized misinterpret and feelings. mingle to other feelings. discussion of negative believe references are roommates. >Always stays in his bed.
Source:
>Only interacts to nurses, doctors, family members and student nurses.
a/what_causes_bp.htm
personal problems within clients hearing.
http://bipolar.about.com/cs/bpbasics/
>Listened attentively to what the patient says.
.
>Provided positive reinforcement.
A> Ineffective denial related to inability to tolerate the consequences of known disorder.
Edx> Encouraged patient to continue verbalizing thoughts and feelings.
Assessment Blood
to him.
pressure above normal parameters ranges from 120/70 to 150/100
Explanation of the Problem The client is then experiencing hypertension that causes imbalance between the oxygen supply and demand.
Objectives
Interventions
After 8 hours of nursing intervetions, the patient will be able to verbalize understanding of
Dx> Monitored and recorded vital signs, noting blood pressure > Noted treatmentrelated factors, such as side effects or
STO:
> Showing interest while the patient talks boost his confidence to share more. > Positive reinforcement will help the patient change his mood like sadness, but limitations should be set so that you won’t be giving negative result to the behavior of the client. 30 >help the client relieve stress and you will be able to know how to be therapeutic
Rationale of the Interventions > this will serve as baseline data > sometimes these are not recognized by the clients, therefore
Expected Outcome
Goal met if the patient is able to verbalize understanding of individual factors that
ASSE
NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER EXPLANATION OF THE GOALS AND INTERVENTIONS RATIONALE PROBLEM OBJECTIVES
EXPECTED OUTCOME
S>” Hypertension P/Dx> Observed > Shows if the patient STO: NCP POTENTIALOne #1:cause RISK of FOR INJURY R/T IMBALANCE BETWEEN OXYGEN SUPPLYresponses AND DEMAND could SECONDARY HYPERTENSION bipolar disorder is STO: naman talaga ang behavioral interactTO and Goal met if the stressful life events these are After 1-2 hours of interested to patient was able problema ko. thought to be the main element in appropriate nursing therapeutic regimen to feelings Hindi ako baliw. the development of bipolar intervention the congruent with Wala naman patient will verbalize >Assessed ability to behavior. disorder. In our patients case one akong nakikita o feelings congruent respond or interpret > To explore hidden factor that could be seen is the nakakausap o with behavior. questions. thoughts and feelings loss of his job making his wife naririnig na gaya that the patient might LTO: work for him and one more thing ng naririnig at LTO: After 2-3 days not show through his Goal met if is that he is left alone while his nakikita ng ibang of appropriate facial expressions. patient meet wife is abroad. kasamahan ko dito.”
O> Does not mingle to other roommates.
A symptom of bipolar that contributes for the patient to deny his known illness is exaggerated self-esteem.
>Always stays in his bed.
Source:
>Only interacts to nurses, doctors, family members and student nurses.
a/what_causes_bp.htm
nursing interventions > Assessed triggering the patient will meet factor that may stop psychological needs your client from talking as evidence by to you. appropriate expression of Tx> Minimized feelings. discussion of negative personal problems within clients hearing.
psychological needs as evidence by appropriate expression of feelings.
http://bipolar.about.com/cs/bpbasics/
>Listened attentively to what the patient says.
.
>Provided positive reinforcement.
A> Ineffective denial related to inability to tolerate the consequences of known disorder.
Edx> Encouraged patient to continue verbalizing thoughts and feelings.
Assessment Blood
> knowing the trigger factors could help you determine what to do if the patient shows. > Client may misinterpret and believe references are to him.
pressure above normal parameters ranges from 120/70 to 150/100 Intake of hypertensive agents like catapres and norvasc Complains of easy fatiguability A>Risk for injury related to imbalanced between oxygen supply and demand secondary to hypertension.
Explanation of the Problem The client is then experiencing hypertension that causes imbalance between the oxygen supply and demand. This imbalance causes alteration in the brain cell functioning leading to decreased perceptual function as manifested by dizziness when standing suddenly, decreased concentration and easy fatigability Source: Brunner and Suddarth’s MedicalSurgical Nursing 7 th edition
Objectives STO: After 8 hours of nursing intervetions, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury.
Interventions Dx> Monitored and recorded vital signs, noting blood pressure > Noted treatmentrelated factors, such as side effects or interactions of medications > Noted client’s age, gender, developmental stage, decision-making ability, level of cognition or competence
Tx> Provided information regarding After 1 to 2 days disease or conditions of nursing that may result in interventions, the increased risk of patient will be able to injury demonstrate > Assisted client to behaviors, lifestyle develop plan for changes to reduce activity and exercises risk factors and within individual protect self from ability injury. > Provided diversional activities, avoiding overstimulation and understimulation LTO:
> Showing interest while the patient talks boost his confidence to share more. > Positive reinforcement will help the patient change his mood like sadness, but limitations should be set so that you won’t be giving negative result to the behavior of the client. 30 >help the client relieve stress and you will be able to know how to be therapeutic
Rationale of the Interventions > this will serve as baseline data > sometimes these are not recognized by the clients, therefore increasing their susceptibility to injury > these affects clients ability to protect self and/or others and influences choice of interventions and/or teachings > this helps the patient to control his condition, thus preventing the risk for injury > to promote active and positive view of self >participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness and worthlessnesss
Expected Outcome
Goal met if the patient is able to verbalize understanding of individual factors that contribute to possibility of injury.
Goal met if the patient is able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
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Edx> Cautioned the patient to avoid activities requiring alertness until the effects of medications are known > Instructed client
> antihypertensive agents usually causes drowsiness which is one of the most common cause of injury > to protect self from injury > to prevent risk for
Assessment Blood
pressure above normal parameters ranges from 120/70 to 150/100 Intake of hypertensive agents like catapres and norvasc Complains of easy fatiguability A>Risk for injury related to imbalanced between oxygen supply and demand secondary to hypertension.
Explanation of the Problem The client is then experiencing hypertension that causes imbalance between the oxygen supply and demand. This imbalance causes alteration in the brain cell functioning leading to decreased perceptual function as manifested by dizziness when standing suddenly, decreased concentration and easy fatigability Source: Brunner and Suddarth’s MedicalSurgical Nursing 7 th edition
Objectives
Interventions
STO: After 8 hours of nursing intervetions, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury.
Dx> Monitored and recorded vital signs, noting blood pressure > Noted treatmentrelated factors, such as side effects or interactions of medications > Noted client’s age, gender, developmental stage, decision-making ability, level of cognition or competence
Tx> Provided information regarding After 1 to 2 days disease or conditions of nursing that may result in interventions, the increased risk of patient will be able to injury demonstrate > Assisted client to behaviors, lifestyle develop plan for changes to reduce activity and exercises risk factors and within individual protect self from ability injury. > Provided diversional activities, avoiding overstimulation and understimulation LTO:
Rationale of the Interventions > this will serve as baseline data > sometimes these are not recognized by the clients, therefore increasing their susceptibility to injury > these affects clients ability to protect self and/or others and influences choice of interventions and/or teachings > this helps the patient to control his condition, thus preventing the risk for injury > to promote active and positive view of self >participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness and worthlessnesss
Expected Outcome
Goal met if the patient is able to verbalize understanding of individual factors that contribute to possibility of injury.
Goal met if the patient is able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
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Edx> Cautioned the patient to avoid activities requiring alertness until the effects of medications are known > Instructed client to request assistance as needed > Advised the patient to report any adverse reactions or side effects of the medication taken
> antihypertensive agents usually causes drowsiness which is one of the most common cause of injury > to protect self from injury > to prevent risk for injury and give prompt attention to side effects as necessary
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NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE Assessment O > Has interest in treasure hunting
Explanation of the Problem Worked as a farmer with family early in
Objectives STO > After 6-8 hours of nursing
Nursing Interventions Dx > Assessed client’s perception of self
Rationales > to determine causative factors
Evaluation STO > Patient was able to
Edx> Cautioned the patient to avoid activities requiring alertness until the effects of medications are known > Instructed client to request assistance as needed > Advised the patient to report any adverse reactions or side effects of the medication taken
> antihypertensive agents usually causes drowsiness which is one of the most common cause of injury > to protect self from injury > to prevent risk for injury and give prompt attention to side effects as necessary
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NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE Assessment O > Has interest in treasure hunting and going outside naked when the wife goes back to Iran. > Returns back to his usual self when the wife is back home. A > Risk for relapsed episode maybe r/t poor medical treatment regimen compliance
Explanation of the Problem Worked as a farmer with family early in the morning to afternoon from childhood to adult. Completed his education till college level and later got married and have children. Went to Iran and worked abroad to help support his family. Came back to the Philippines and continue working for his family. Wife had gone back to Iran to work, leaving the husband and son in Philippines. Then husband start acting strange with interest of treasure hunting and going outside naked. But returns normal when wife comes back home.
Objectives
Nursing Interventions
STO > After 6-8 hours of nursing intervention patient is able to show signs coping measures.
Dx > Assessed client’s perception of self and noted use of defense mechanisms. > Assessed clients coping behaviors already LTO > After 1-2 present. hours of nursing > Reviewed intervention patient laboratory and is able to medication chart. understand the Tx > Developed importance of his therapeutic treatment and nurse-patient verbalize his relationship. feelings. > Maintained straight forward communication. > Listened to feelings that he expresses. > Being truthful when giving information and dealing with patient. > Invited client to do activities. > Gave positive reinforcement for
Rationales > to determine causative factors > to determine signs of relapse. > to determine contributing factors. > promotes sense of trust, allowing patient to discuss feelings openly. > to avoid reinforcing manipulative behavior. > offer emotional support and understanding. > builds trust, enhancing therapeutic relationship.
Evaluation STO > Patient was able to demonstrate coping mechanism as evidenced by relaxed posture and calm behavior. LTO > Patient was able to understand about his treatment by taking his medications as scheduled and informing any changes of behaviors.
> for positive distraction. > encourages continuation of treatment. > decreases defense 33
client’s efforts. > Maintained calm, matter of fact, nonjudgmental attitude. Edx > Encouraged client to get adequate sleep. > Instructed client to take medication as
response. > to prevent fatigue. > to help to deal with stress. > to understand that it is a long term treatment.
NCP POTENTIAL #2: RISK FOR RELAPSED EPISODE MAYBE R/T POOR MEDICAL TREATMENT REGIMEN COMPLIANCE Assessment O > Has interest in treasure hunting and going outside naked when the wife goes back to Iran. > Returns back to his usual self when the wife is back home. A > Risk for relapsed episode maybe r/t poor medical treatment regimen compliance
Explanation of the Problem Worked as a farmer with family early in the morning to afternoon from childhood to adult. Completed his education till college level and later got married and have children. Went to Iran and worked abroad to help support his family. Came back to the Philippines and continue working for his family. Wife had gone back to Iran to work, leaving the husband and son in Philippines. Then husband start acting strange with interest of treasure hunting and going outside naked. But returns normal when wife comes back home.
Objectives
Nursing Interventions
STO > After 6-8 hours of nursing intervention patient is able to show signs coping measures.
Dx > Assessed client’s perception of self and noted use of defense mechanisms. > Assessed clients coping behaviors already LTO > After 1-2 present. hours of nursing > Reviewed intervention patient laboratory and is able to medication chart. understand the Tx > Developed importance of his therapeutic treatment and nurse-patient verbalize his relationship. feelings. > Maintained straight forward communication. > Listened to feelings that he expresses. > Being truthful when giving information and dealing with patient. > Invited client to do activities. > Gave positive reinforcement for
Rationales > to determine causative factors > to determine signs of relapse. > to determine contributing factors. > promotes sense of trust, allowing patient to discuss feelings openly. > to avoid reinforcing manipulative behavior. > offer emotional support and understanding. > builds trust, enhancing therapeutic relationship.
Evaluation STO > Patient was able to demonstrate coping mechanism as evidenced by relaxed posture and calm behavior. LTO > Patient was able to understand about his treatment by taking his medications as scheduled and informing any changes of behaviors.
> for positive distraction. > encourages continuation of treatment. > decreases defense 33
client’s efforts. > Maintained calm, matter of fact, nonjudgmental attitude. Edx > Encouraged client to get adequate sleep. > Instructed client to take medication as ordered. > Explained to client symptoms improve gradually and not immediately. >Advised client to report mood changes immediately. > Educated client to not stop on medication without physician’s order.
response. > to prevent fatigue. > to help to deal with stress. > to understand that it is a long term treatment. > to make adjustments in the treatment. > to prevent relapse.
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client’s efforts. > Maintained calm, matter of fact, nonjudgmental attitude. Edx > Encouraged client to get adequate sleep. > Instructed client to take medication as ordered. > Explained to client symptoms improve gradually and not immediately. >Advised client to report mood changes immediately. > Educated client to not stop on medication without physician’s order.
response. > to prevent fatigue. > to help to deal with stress. > to understand that it is a long term treatment. > to make adjustments in the treatment. > to prevent relapse.
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35
I. DISCHARGE PLAN
DIET AND NUTRITION Instructed
client to eat frequent small
meals Instructed
to have high protein, high
ACTIVITY
Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Cleaning,
HEALTH TEACHINGS Teach
client to take medications
regularly
Instruct the wife that whenever she see
35
I. DISCHARGE PLAN
DIET AND NUTRITION Instructed
client to eat frequent small
ACTIVITY
meals Instructed
to have high protein, high
carbohydrate diet for energy
Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Cleaning, reorganizing, reading, or raising goldfish could all be great indoor activities. Creative activities like occupational therapy, drawings Medications should be given regularly everyday for a certain period of time
Make client be more active and cooperative in any activities given to him
Instruct client to do activities that do not require alertness because one side effect of medication is drowsiness, thus may cause injury to the client
HEALTH TEACHINGS Teach
client to take medications
regularly
Instruct the wife that whenever she see signs and symptoms of B ipolar Disorder to refer him immediately
Teach
the client on the side effects of
his medicines when not taken
Advise the client to go back to the institution after discharge for follow-up check-up and consultation
36
J. CONCLUSIONS AND RECOMMENDATIONS Bipolar disorder causes serious shifts in mood, energy, thinking and
I. DISCHARGE PLAN
DIET AND NUTRITION Instructed
client to eat frequent small
ACTIVITY
meals Instructed
to have high protein, high
carbohydrate diet for energy
Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Cleaning, reorganizing, reading, or raising goldfish could all be great indoor activities. Creative activities like occupational therapy, drawings Medications should be given regularly everyday for a certain period of time
Make client be more active and cooperative in any activities given to him
Instruct client to do activities that do not require alertness because one side effect of medication is drowsiness, thus may cause injury to the client
HEALTH TEACHINGS Teach
client to take medications
regularly
Instruct the wife that whenever she see signs and symptoms of B ipolar Disorder to refer him immediately
Teach
the client on the side effects of
his medicines when not taken
Advise the client to go back to the institution after discharge for follow-up check-up and consultation
36
J. CONCLUSIONS AND RECOMMENDATIONS Bipolar disorder causes serious shifts in mood, energy, thinking and behavior from the highs of mania on one extreme to the lows depression on the other. More than just a fleeting good or bad mood swings, the cycles of bipolar disorder last for days, weeks, months or even a year. Unlike ordinary mood swings, the mood changes bipolar disorder is so intense that they interfere with your ability to function. People experiencing a manic episode often talk a mile a minute, sleep very little and are hyperactive. Interaction with the patient for more than 3 days is not enough to cover from his childhood up to now. We should interact with the patient more and more to know about his history and different traumas that he encountered. Well preparation to go on duty at the area should be done before the actual duty by conducting self awareness test. We should also be well knowledgeable to psychiatric disorders prior to duty to enhance more our interventions and interactions. Since the client has Bipolar Disorder, the group concluded that this disorder has different symptoms as compared to the other psychiatric disorders. Therefore, in the making of this case study and understanding how this disorder affects a person through appreciating it’s pathophysiology. This study makes us student nurses more competent and gained more confidence in handling patients with Bipolar Disorder.
