West Visayas State University COLLEGE OF NURSING La Pa, Iloilo City NURSING PROCESS: MALADAPTIVE PATTERNS OF BEHAVIOR A.

PSYCHIATRIC NURSING HISTORY I. General Data Name: M.G.D.C. Age: 34 years old Civil Status: Single Nationality: Filipino Occupation: None Address: Brgy. Palina, Concepcion, Iloilo II. Chief Complaint My Mom brought me here for check-up, as verbalized by the patient. Hindi na kasi siya kumakain o umiinom ng tubig, as verbalized by the watcher. III. History of Present Illness Four years prior to confinement, MGDC worked in an electronics company. She was fired because she was often absent. Two years prior to confinement, she ventured into a mining or a company involving selling gold and other elements. She told her father that she is marrying a male business partner. Her father disagreed to this, because they have a different religions. She broke that engagement. After sometime, she had an argument with one of her business partner, whom she stabbed. Then, she was imprisoned. Her mother did not disclose the duration of imprisonment. She was diagnosed to have depression. She had a flat affect and is always crying. She was fetched by her mother. They went back to their hometown. There she was able to talk normally and she did not show any signs of depression. She was able to perform daily activities like cooking, gardening, and others. She was always gambling; a habit scolded by her mother most of the time. Five months prior to confinement, her father died. Still, she was able to perform her normal activities. One month prior to confinement, she went to visit her female partner s house in Negros. She found out that her partner would be married soon. Her former partner s parents gave her a brown bag, full candies. When she returned from the said visit, she complained of a severe headache and she took multivitamins, but this intervention was not effective. Three weeks prior to confinement, she was not talking and she had a flat affect. Two weeks prior to confinement, she was not eating and she drinks water once per two days. She kept on holding her brown bag. She shouts at her mom, and accuses her of planning to poison her. She also wanders late at night. With this condition, her mother and brother decided to bring her to West Visayas State University Medical Center for check-up. Thus, this admission. IV. Past History Client was diagnosed with depression. Her mother fetched her from the hospital (name of hospital was unrecalled by her mother.) Upon discharged, her mother claimed that she had no maintenance or any medication needed for daily intake. The client does not take illicit drugs. She is an occasional drinker. She drinks only in occasions, which happens once in a month. She had no previous head injury or trauma, convulsions or tumors.

V. Family History Her cousin in the mother side was diagnosed with schizophrenia. In addition, her uncle in the mother side had experience periods of severe depression. VI. Past Personal History A. Prenatal History The mother was 28 years old when she gave birth to the patient in their house. The mother always ate vegetables and she does not leave the place at night. She also sees to it that she does not see many negative events so that it will not affect her pregnancy. She had no difficulties during pregnancy. She does not go to any prenatal clinic because she claims that she has no pain or any abnormal feelings felt that time. B. First year of Life She was weaned around age 1 or 1 and 6 months. She does not nail-bite. The age of dentition, crawling, first word uttered and learning to stand, walk, talk ranges from the first year to second year. The exact month was unrecalled by the mother. C. Toilet training The mother claims that she is not that strict when she was toilet training her daughter. D. Secondary Socialization As a kid, client was very friendly. She would invite her classmates to have lunch in their house. When she got older, she became more secretive and her mother would meet either 1 or 3 of her friends from work. Though not sporty, she engages in other cocurricular activities in school. She is friendly and generous. Oftentimes, she would bring her classmates at home or share her lunches with them. The client is more of an independent teenager. She always had her way with her activities and friends. The only thing that her mother decided for her is to take the course she graduated in. the client wanted to take something related to clerical work but, she did not pushed through with condition because they have to consider the financial resources of the family. FAMILY MEMBER FATHER RELATIONSHIP WITH THE FAMILY MEMBER PATIENT ALWAYS FOLLOWS WHAT HER FATHER TELLS HER, SHE IS CLOSER TO HER DAD THAN HER MOM; FATHER MOVED TO ZAMBOANGA WHEN SHE WAS 4-5 YEARS OLD MOTHER SHE ALWAYS SCOLDS HER ALWAYS AND DOES NOT SHOW APPRECIATION A LOT; BUT, THEY GET ALONG WELL. OLDER BROTHER THEY GET ALONG QUITE WELL; BUT, THEY ARE NOT THAT CLOSE, HIS BROTHER LIVES AWAY FROM HOME YOUNGER BROTHER SHE IS CLOSER TO THIS BROTHER. SHE IS THE CONFIDANTE OF THE SISTER E. School History The mother said that she was not does not top the class; generally, she was an average student. She joins a lot of extra-curricular activities. F. Home Environment (SNs were not able to conduct a home visit in client s house.)

G. Interests, Hobbies and Habits Client loves reading books. She has a wide variety of books and she speaks English well. She loves taking care of kids. When asked if she used to play sports, she said that she knows the rules but was never an expert in any sport or game. H. Marital History Client was not able to disclose her sexual affairs. As said by the watcher, the client is a bisexual. She had 1 or 2 female partners. And, she was almost married to a male business partner. I. Current social situation and Home Environment (SNs were not able to do home visit.) J. Premorbid Personality The client has always been secretive. According to the mother, she is generally secretive and chooses not to express her problems. Maybe because she does not want to add to the burden of the family so she keeps things to herself. She always tries to make a solution out of his stressors. She had many frustrations with her life and she has just undergone the loss of his father. She has no partner and employment before the onset of the symptoms. She is often alone at home and the only thing close to an activity that she has is playing gambling with her aunts.

VII. Mental Status Examination MENTAL STATUS GUIDE ASSESSMENT TOOL Appearance: how the client Clad in slightly dirty clothes, looks; the overall image fairly kempt in grooming, hair projected by the client. tied, attended to her hygiene poorly, fingernails are short and dirty, a little sluggish in movement and locomotion and has slightly slouched posture.

Affect: observable expression Shows a blunted affect, does of emotion; the more not readily converse to immediate emotional tone. student nurses and maintains her affect for a period of time but there are times when she smiles with hesitation.

Mood: a pervasive and subjectively experience feeling state; colors the person s world view; mood is a long-termed sustained emotion

Not conversant to student nurses and always assumes a lying position on her bed, does not go out during therapies and other activities; when she is forced or stop from what she wants to do, she can exhibit anger.

Memory: the client s ability to Immediate, Recent and recall. Remote memory were not assessed since our patient is non-conversant.

Attention: the ability to Does not give focus on a sustain a focus on one task. single task and does not want to have student nurses staying with her, when people are around her she usually leaves her place and transfers to another comfort zone. Eye contact Patient does not give and Eye contact often decreases maintain an eye contact with with increasing anxiety or the student nurses. paranoia; patients who cannot concentrate on the interview may not focus on the interviewee visually. Motor Activity: the way the During the interview the The patient has less capacity client moves. patient assumes a fetal lying to maintain a normal body

CLINICAL PRESENTATION Manner of dress can provide clues to client s self image; depressed and schizophrenic patients that are usually well groomed and gives focus to their hygiene is prevented by their disorders from attending to their daily hygiene and cannot maintain a clean appearance without support. Blunted affect and emotional hesitation is usually seen in Schizophrenia patients; may also be seen in patients taking anti-psychotic medications. Patients especially with does not readily give trust to people that is also the reason why they cover up facial expressions. Mood may vary from person to person but patients having paranoid schizophrenia are consciously afraid of their environment, this may be a contributory factor for them to stay in one place and have steady single mood. They are easily angered; with stimulation they can express an angry mood. In cases where concentration is impaired patients may be unable to attend to tasks and will appear to have memory deficits when none exists. Lack of attention is an indication of thought disturbance.

position facing the student nurses and does not change in position; a little sluggish in movement and locomotion and has slightly slouched posture.

Speech: is a hybrid of what one may observe and the thought processes of the client.

Delusions: a false belief firmly held despite incontrovertible and obvious proof or evidence to the contrary; the belief is not one ordinarily accepted by other members of the client s culture or subculture. Intellect: the client s basic When asked about the knowledge and awareness of president of the Philippines social events. she answered Noynoy . She is a graduate of Education major in English. Judgment: the ability to make Patient did not answer the and carry out plans and to question when she was asked discriminate accurately and what will you do when you behave appropriately in social smell smoke when in a movie events. house?

Though the patient does not speak a lot and nonconversant, she sometimes talk to a female folk and she has a good English diction and enunciation, the volume of her voice is low and speaks in a normal pace. There are no sign of delusions Delusions are hallmarks of during nurse-patient psychotic illness especially interaction, since the patient Schizophrenia. is non-conversant. Patient uses and believes her urinal is a form of a drinking cup.

alignment and control, posture and movements can be related to attitude, patients gait may indicate anxiety and paranoia; depressed patients may demonstrate slumped posture and slow gait; slow movement and little reactivity may indicate depression and schizophrenia. Provides information about the thought processes; Schizophrenic patients especially paranoid ones does not talk a lot and talks in a low voice, same with patients that are depressed.

This may be indicative of how the patient will be treated. Schizophrenic patients though not all of them have high intellectual level. Judgment may vary depending on cultural beliefs, norms and age bracket. There is a need for a response from the patient in assessing for judgment. Hallucination: perceptions the There are no sign of Hallucinations are hallmarks client believes to be real hallucinations during nurse of psychotic illness especially despite evidence to the patient interaction. Schizophrenia. contrary; the client perceives something that does not exist; may involve any of the five senses. Insight into Problems: client s Client stated that she is not Insight into problem is awareness and understanding sick, and she s strong and particularly impaired in of their illness there s nothing wrong about psychotic patients; this will her. determine their degree of compliance and perception of current situation Orientation: awareness of Client is not able to exhibit Confusion or clouding or time, place, person, situation orientation to time, place, consciousness might be person and situation. She is determined through this

non-conversant. Though content: ideas the Client is non-conversant. client communicates; client s ideas about themselves and the world Suicidal Ideation: desire to Client is non-conversant; harm oneself or end one s life client did not participate in the art therapy, an exercise that could help them express themselves. Homicidal Ideation: desire to Client is non-conversant; she do serious harm to or to take has a tendency to be violent, the life of another person especially when restrained. No verbal expression of wanting to harm others. Thought Process: the way the Client is non-conversant; client puts ideas together; the association between ideas and to the form and flow of thoughts in conversation Interview Behavior: the The client does not readily client s response to the give response or interviewer. communicate to the student nurses, as the questions are raised the patient become less comfortable with the situation, and the patient does not show an ability to show alliance with the student nurses.

exam; may also be a good indicator of drug toxicity In depressed patients, morbid preoccupations are often manifested. If suicidal ideations are present, this may indicate lack of opportunity for expression and a strong support person. People who are depressed and lack support system are at high risk to act or follow these thoughts. Client must manifest slow or retarded processing of thoughts.

Provides an indication of the client s motivation for treatment. Patient at this point is not ready or does not want to engage in the treatment regimen; paranoid individuals are typically suspicious, evasive, and arrogant; Schizophrenic patients are reserved, remote and seemingly unfeeling; depressed patients appear apathetic, hopeless, and helpless.

VIII. Diagnosis Formulations or Nursing Impression 1. During the entire duration of nurse-patient interaction, from the orientation phase up to the termination phase, we found out that our client's central problem is ineffective coping. She continues to disclose herself on the student nurses and denies to herself that she's ill and that she doesn t need treatment. All of the things that had happened to her have precipitated to her present condition. She was unable to perceive the reality and she is afraid to face it. She sticks on the situation at the point of her life when she feels stable at most, that is when she has her work and is able to support her family, and she had a happy intimate relationship, and; when she does whatever she wants. She blocks the thoughts of being rejected. At the time that she can't use her defense mechanisms effectively, she sees things negatively (e.g., when her mother reminded her of her attitude of going home late and gambling too much). She tend to keep away from people. Little by little, she tried to cope when she saw a new girl in the ward and she could have thought that it was her girlfriend which can result again to another frustration if that girl in the ward would reject her someday. 2. Her mother and brother are always there to look after her but she hates them both so the family members are just there but is not able to help her because she pushes them away. The contributory problems that we have identified are: a) when she and her fianc broke-up because of difference in religion; b) when her parents disapprove her sexual orientation of being a lesbian c) when her "girlfriend" left her and married another man d) when she was scolded by her mother every time she gets home late because of gambling e) unemployment f) she has no outlet or support network 3. Conceptualization of client's problem The Eagle is meant to fly and wind through the endless spheres. The Eagle went out of its nest thinking that she could finally be her own person. Little did she know, she had a weak tarsus, her feet. She slowly glided in the nearby tree and hopped to another tree. She fell in love with a fellow hen. But, the hen saw her mate and left her. Her wings were left to be bleed. She went to a desert and found a cock. But, she has leave to him too. Again, her wing bleed some more. Until it bleed and bleed, she plead, Help, help, help No one sees what s inside. She locked herself in a cage. She had enough of her past, because the present is too much bare. She imprisoned herself in the past, where she would not be vulnerable. By the river of unknown, she hid and wept. 4. Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Depressed A. Currently (or most recently) in a Major Depressive Episode. B. There has previously been at least one Manic Episode or Mixed Episode. C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder Delusional Disorder, or Psychotic Disorder Not Otherwise Specified If the full criteria are currently met for a Mixed Episode, specify its current clinical status and/or features: Mild, Moderate, Severe Without Psychotic Features/ Severe With Psychotic Features Chronic With Catatonic Features

With Melancholic Features With Atypical Features With Postpartum Onset If the full criteria are not fully met for a Major Depressive Episode, specify the current clinical status of the Bipolar I Disorder and/or features of the most recent Major Depressive Episode: In Partial Remission, In full Remission Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset Specify: Longitudinal Course Specifiers (With and Without Interepisode Recovery) With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes) With Rapid Cycling Diagnostic Criteria for Schizophrenia A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). Paranoid Type A type of Schizophrenia in which the following criteria are met:

IX. Psychodynamic Formulation Stage of Developmental task Development according to Freud /Erickson textbook Oral Major site of tension (birth to 18 months) and gratification is the mouth, lips, and tongue; includes biting and sucking activities.

Developmental task of client

Analysis Client was able to accomplish the oral stage. She also accomplished the trust stage. Primary caregiver was able to provide trust to client. People who are fixated in this stage often have oralrelating habits. They also have difficulty trusting to other people.

Her mother was her primary caregiver when she was a baby. She was breastfed and her mother was able to meet her needs immediately. Id present at birth. Client is not smoking, nail biting or does Ego develops have other oral gradually from habits. rudimentary structure present at birth.

Trust vs. Mistrust (infant)

Viewing the world as safe and reliable; relationships are nurturing, stable and dependable. Anal Anus and surrounding At this stage, she was People who had strict (18-36 months) area are major source being weaned and toilet training tend to of interest. being toilet trained. be perfectionist. The superego complex Acquisition of dominates the voluntary sphincter personality. control (toilet She was able to attain training) autonomy. People who did not Autonomy vs. Shame Achieving a sense of accomplish autonomy and doubt control and free will tend to be overly (toddler) independent which is also associated with the weaning age. Phallic/oedipal Genital focus of Every time she does Elektra complex was (3-5 years) interest, stimulation something, her not fully resolved and excitement mother would not since her father show appreciation moved temporarily to Penis is organ of and always Zamboanga City. interest for both disapproves or A fixation at this stage sexes. disagrees with what could result in sexual she does. deviancies (both Masturbation is overindulging and common. Father temporarily avoidance) and weak worked in Zamboanga or confused sexual Penis envy (wish to City. identity. possess penis) seen in girls; oedipal complex No sibling rivalry (wish to marry experienced. opposite- sex and be

rid of same-sex parent) seen in boys and girls Initiative vs. Guilt (pre-school) Beginning development of a conscience; learning to manage conflict and anxiety Resolution of oedipal She does well in complex school and she is active in school. She is Sexual drive an average student channelled into and her mother has socially appropriate not received any activities such as report of complaints school work and against her. Client sports was able to win in competitions such as Formation of the speech-related superego competitions. She is friendly. Final stage of psychosexual development Emerging confidence in own abilities; taking pleasure in accomplishments Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy

Latency (5-11 or 13 years)

Able to achieve industry stage. Selfesteem is associated with inferiority and could later lead to depression in adult age. Children in this stage must be busy with building, creating and accomplishing things. Client was able to achieve virtue of competence such as communication.

Industry vs. Inferiority (school age)

Genital (11-13 years)

Identity vs. confusion (adolescence)

During her adolescence, she is able to socialize mingle with others. Her mother stated that she has many Role Formulating a sense male friends more of self and belonging than female. She was not able to choose a course that suits her preferences and ambitions. She was always with his male siblings.

Intimacy vs. Isolation (young adult)

Forming adult, loving relationships and meaningful attachments to others

She earned her degree as a registered teacher but did not work as a teacher instead, she worked in an electronics company. But, she

Stage of reshaping the superego and greater independence. She did not overcome role confusion. People in this stage engage in groups and identify with the group. In her case, she was exposed a lot to the masculine side. Role confusion often develops if the person has an unclear view of one self. Fixated in isolation; isolation is marked by separation from other and view others as dangerous. People who are fixated in previous stages will

Generativity Stagnation

was fired because she has a lot of unexcused absences. She was the one who supported her family and sent her brother to school. She had been involved in several relationships in different sexual orientation. She had a female partner for more than 2 years. She had a fiance but they broke up because the father was against the relationship vs Being creative and She has no family yet. productive; She is unemployed establishing the next and she has no output duration that would harness her potential. She went to Negros and went to the girl's family. When she came back to their home, she spent her time on gardening. In fact, she has a wide garden of variety of vegetables. She also spent her time gambling (playing tong-its) with her aunts and neighbourhood. Her mother would scold her every time she gets home late at night because she always does this.

find it hard to achieve the next stage. The two main goals in this stage are to love and work. If these tasks are not achieved, they are at higher risk for development of social isolation, depression and suspicion.

Tasks in this stage include raising children, guiding new generation, creativity and altruism. Selfconcern, isolation and absence of intimacy are characteristics of stagnation. If generativity is not achieved, a person is prone to depression and substance abuse such as alcohol.

X. Psychopathology
Predisposing factors y y y y Chemical biologic imbalances Psychosocial stressors Interpersonal events Genetic factors (first-degree relative) y Number of child born (identical twins>fraternal twins) y Endocrine disorders (thyroid, adrenal, parathyroid and pituitary Precipitating factors y Interpersonal events (conflicts at work which resulted to unemployment)

Increased anxiety

Use of defense mechanisms (denial, sublimation, displacement, resistance)

additional stressor (broken relationships, family conflicts

defense mechanism breakdown

Ineffective individual coping

ego disintegration

maladaptive use of defenses

Psychosis: SCHIZOPHRENIA

Psychopathology (according to Biologic Theories): Depression

Predisposing factors y y y y Chemical biologic imbalances Psychosocial stressors Interpersonal events Genetic factors (first-degree relative) y Number of child born (identical twins>fraternal twins) y Endocrine disorders (thyroid, adrenal, parathyroid and pituitary Precipitating factors y Interpersonal events (conflicts at work which resulted to unemployment)

y Higher rate of mixed and rapid cycling y Poor response to lithium y Slow rate of recovery

genetic overlap

Altered balance of neurotransmitters

Hormonal fluctuations

Deficits of serotonin, tryptophan (its precursor), or a metabolite (5hhydroxyindole acetic acid, or 5-HIAA) in the blood or CSF (cerebrospinal fluid)

Elevated glucocorticoid levels associated with stress reponse

Dysregulation of dopamine Dysregulation of acetylcholine

Elevated TSH (thyroid-stimulating hormone)

Increased norepinephrine

Deficient norepinephrine

mania

depression

Energizes the body to mobilize during stress and inhibits kindling (the process by which seizure activity in a specific area of the brain is initially stimulated by reaching a threshold of the cumulative effects of stress, low amounts of electric impulses, or chemicals that sensitize nerve cells and pathways)

Highly sensitized nerve cells and pathways) respond without stimulus to induce seizure activity

Psychopathology (according to Biologic Theories): Schizophrenia, Paranoid Type

Predisposing Factors y Genetics (immediate families) Twins (identical twins: 50%; fraternal twins: 15%) One parent: 15%; both parents:35% Neuroanatomic and neurochemical factors Immunovirology Intrauterine influences (poor nutrition, tobacco, alcohol and other drugs, and stress) Dysfunctional relationships and adolescence Dysfunctional parenting or family dynamics Precipitating Factors y y Dysfunctional relationships and adolescence Dysfunctional parenting or family dynamics

y y y

y y

unknown

virus

trauma

Immune response

Less brain tissue and Ecerebrospinal fluid

Failure in development or subsequent loss of tissue

Enlarged ventricles in the brain and cortical atrophy

Diminished oxygen and glucose metabolism in the frontal cortical structures of the brain

Decreased brain volume and abnormal brain function in the frontal and temporal areas

Psychosis (temporal lobe) Lack of volition or motivation and anhedonia (frontal lobe)

Neuronal networks malfunction

Failure of information to be transmitted by electrical signals from a nerve cell through its axon and across synapses to postsynaptic receptors on other nerve cells

Drugs that increase activity in the dopaminergic system

Drugs blocking post-synaptic dopamine receptors

Excess dopamine

Serotonin modulates and helps to control excess dopamine

Excess serotonin

SCHIZOPHRENIA

XI. Specific Nursing Problems and Interventions Problem List Interventions and Rationale Ineffective Coping Provide a safe environment Manifestations of the for the client. Patient: y Refuse to verbalize or Rationale: Physical safety of a client is a priority. Many express feelings common items may be used in y Avoids contact with a self-destructive manner. other people especially with men Continually assess the client's potential for suicide. Remain aware of this suicide potential at all times. Rationale: Depressed clients may have a potential for suicide that may or may not be expressed and that may change with time. Observe the client closely, especially under the following circumstances: After antidepressant medication begin to raise the client's mood. y Unstructured time on the unit or times when the number of staff on the unit is limited. y After any dramatic behavioural change (sudden cheerfulness, relief, or giving away personal belongings). Rationale: You must be aware of the client's activity at all times when there is a potential suicide or self-injury. Risk for suicide increases as the client's energy level is increased by medication, when the client's time is unstructured, and when observation of the client decreases. These changes may indicate that the client has come to decision to commit suicide. Reorient the client to person,

Date Resolved Unresolved. Client was encouraged to cry and she cried however, she was unable to verbalize her feelings. She still uses denial as her defense mechanism. She states, "I am well now. I may not be here next week or the next day," which unrealistic because her major problem was not being processed and she is resistant to disclose the issue.

place, and time as indicated (call the client by name, tell the client your name, tell the client where he or she is, and so forth). Rationale: Repeated presentation of reality is concrete reinforcement for the client. Spend time with the client. Rationale: Your physical presence is reality. If the client is ruminating, tell the client that you will talk about reality, or about the client's feelings, but limit the attention given to repeated to expressions of rumination. Rationale: Minimizing attention may help decrease rumination. Providing reinforcement for reality orientation and expression of feelings will encourage these behaviours. Initially assign the same staff to work with the client whenever possible. Rationale: The client's ability to respond to others may be impaired. Limiting the number of new contacts initially will facilitate familiarity and trust. However, the number of people interacting with the client should increase as soon as possible to minimize dependency and to facilitate the client's ability to communicate with a variety of people. When approaching the client, use a moderate, level tone of voice. Avoid being overly cheerful. Rationale: Being overly

cheerful may indicate to the client that being cheerful is the goal and that other feelings are not acceptable. Use silence and active listening when interacting with the client. Let the client know that you are concerned and that you consider the client a worthwhile person. Rationale: The client may not communicate if you are talking too much. Your presence and use of active listening will communicate your interest and concern. When first communicating with the client, use simple, direct sentences; avoid complex sentences or directions. Rationale: The client's ability to perceive and respond to complex stimuli is impaired. Avoid asking the client many questions, especially questions that require only brief answers. Rationale: Asking questions and requiring only brief answers may discourage the client from expressing feelings. Be comfortable sitting with the client in silence. Let the client know you are available to converse, but do not require the client to talk. Rationale: Your silence will convey your expectation that the client will communicate and your acceptance of the client's difficulty in communication. Allow (and encourage) the

client to cry. Stay with and support the client if she desires. And is safe to do so. Rationale: Crying is a healthy way of expressing feelings of sadness, hopelessness and despair. The client may not feel comfortable crying and may need encouragement or privacy. Do not cut-off interactions with cheerful remarks or platitudes (e.g., "No one really wants to die," or "You'll feel better soon.") Do not belittle the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). You may be uncontrollable with certain feelings the client expresses. If so, it is important for you to recognize this and discuss it with another staff member rather than directly or indirectly communicating your discomfort to the client. Proclaiming the client's feelings to be inappropriate or belittling them is detrimental. Encourage the client to ventilate feelings in whatever way is comfortable-verbal and nonverbal. Let the client know you listen and accept what is being expressed. Rationale: Expressing feelings may help relieve despair, hopelessness and so forth. Feelings are not inherently good or bad. You may remain nonjudgmental about the client's feelings and express this to the client. Interact with the client on topics with which she is

comfortable. Do not probe for information. Rationale: Topics that are uncomfortable for the client and probing may be threatening and discourage communication. After trust has been established, the client may be able to discuss more difficult topics. Teach the client about the problem-solving process: explore possible options, examine the consequences of each alternative, select and implement an alternative, and evaluate the results. Rationale: The client may be unaware of a systematic method for solving problems. Successful use of the problemsolving process facilitates the client's confidence in the use of coping skills. Provide positive feedback at each step of the process. If the client is not satisfied with the chosen alternative, assist the client to use another alternative. Positive feedback at each step will give the client many opportunities for success, encourage him or her to persist in problem solving, and enhance confidence. The client can learn to "survive" making a mistake. Encourage the client to establish normal sleep-wake routines by refraining from napping during the day.

Disturbed Sleep Patten Manifestations of the Patient: y Inability to sleep at night and awake early in the morning (3AM), Rationale: Daytime sleeping then tried to escape y asleep or sleepy during will interfere with the client's ability to sleep at night. the day. Suggest establishing night

Unresolved. Not able to gather subjective data regarding quality of sleep.

time routines that induce sleep, such as taking a hot bath or reading a book. Rationale: Avoiding stimulating activities and replacing them with calming ones will help the client prepare for a more restful sleep. Instruct client about medications and the sleepwake schedule. Rationale: Antidepressants do help with restoring normal sleep patterns, but the client may also want to consider a hypnotic agent. Discuss use of depot injections to manage shortterm medication compliance. Rationale: Patient's refusal to take medication suggests that compliance will remain an issue. Depot injections ensure that therapeutic levels of neuroleptic medication can be maintained for two weeks at a time. Initiate medication compliance therapy. Help the client achieve insight into the benefit of taking the medication by helping her review the history of her illness, symptoms and medication side effects and encouraging her to consider the benefits versus the drawbacks of drug treatment. Encourage medication compliance and provide compliance about neuroleptic medication. Rationale: Medication compliance therapy, which involves medication education, support, and

Noncompliance Manifestations of the Patient: y Refuses to take medications y Does not participate in occupational therapy and music and art therapy

Resolved: December 6, 2011 Client received the depot injection and was able to take her medications due at 8am. She also attended the culminating activity the following day.

insight into the disorder, has been shown to increase longterm medication compliance. XII. Evaluation of Interventions Before Client does not speak a single word to SNs.

Client does not display any interest in activities such as hataw and therapies. Client has poor hygiene. Client drinks in the urinal. Client refuses to take medicine. Client does not eat in a specified time. Client isolates herself. XIII. Recommendations or Discharge Plans 1. Medical Management a. Drug Therapy

After Client was able to speak a sentence in front of the group and also corrected pronunciation of SN. Client watched as we exercised. She joined in the guess who game. Client takes bath independently. Client drinks in the cap, but still uses urinal as a pitcher. Client already knows that after eating meals, she has to take her medications. Client eats meals on time. Client mingles with the other patient.

Chlorpromazine HCl y Tell patient to take tablets with a full glass of water, with or without food. y Instruct patient not to crush sustained-release capsules. y Caution patient to avoid hazardous activities until she knows how drug affects concentration and alertness. y As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs (e.g., antihistamines), herbs (e.g., angel's trumpet) and behaviours. Risperidone y Instruct patient to remove orally disintegrating tablet from blister pack, place on tongue immediately, and swallow as tablet dissolves. y Advise patient to use effective bedtime routine to avoid sleep disorders. y Teach patient to recognize and immediately report signs and symptoms of serious adverse reactions, including tardive dyskinesia and neuroleptic malignant syndrome. y Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease. y Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of light-headedness (especially in hot weather). y Caution patient to avoid hazardous activities until she knows how drug affects concentration and alertness. y Advise patient not to drink alcohol. y As appropriate, review all significant and life-threatening adverse reactions and interactions, especially those related to the drugs and behaviors. Haloperidol y Instruct patient to immediately report signs or symptoms of serious adverse reactions, such as unusual weakness, yellowing of skin or eyes, difficulty breathing, or symptoms of neuroleptic malignant syndrome (such as fever, muscle pain or rigidity, rapid or

y y

irregular pulse, increased sweating, change in urination pattern, or decreased mental acuity). Advise patient to minimize GI upset by eating frequent, small servings of food and drinking adequate fluids). As appropriate, review all significant and life-threatening adverse reactions and interactions, especially those related to the drugs and behaviors.

b. Physical Treatment (if needed) The patient does not need physical treatment. 2. Nursing Management Providing for Safety y Determine whether a client with depression is suicidal. Instruct the patient's primary caregiver to observe measures to provide a safety environment as necessary. Promoting a Therapeutic Relationship y Encourage the client's family members to stay with the client for a few minutes at intervals throughout the day. Emphasize that their presence conveys genuine interest and caring for the client. This is also one way for the client to accept her family members and develop trust in them. y It is also important that the family members avoids being overly cheerful or trying to "cheer-up" the patient. It is impossible to coax or to humor client out of her depression. It may also make the client feel worse or convey a lack of understanding of their despair. Promoting Activities of Daily Living and Physical Care y Encourage the client to be independent in performing self-care needs. Give her the opportunity to choose between what she wants to wear and the like. y Encourage the caregivers to allow patient to do light activities at home such as gardening without tools and with supervision, sweeping the floor or disposing the garbage so that she will be able to develop a sense of autonomy and independence. Providing Client and Family Teaching y Teach the client and the family about depression and schizophrenia. They must understand that these are illnesses, not a lack of willpower or motivation. Learning about the beginning symptoms of relapse may assist clients to seek treatment early and avoid a lengthy recurrence. y Client and family should know that treatment outcomes are best when psychotherapy and psychopharmacology are combined. Psychotherapy helps clients to explore anger, dependence, guilt, hopelessness, helplessness, object loss, interpersonal issues, and irrational beliefs. y The nurse can help the client to find a therapist through mental health centers in specific communities. y Support group participation also helps the client and family members. XIV. Bibliography
1. Antai-ong, D. (2003). Psychiatric nursing: biological and behavioural concepts. Delmar. Texas. 2. Carpenito-Moyet, L. (2006). Nursing diagnosis application to clinical practice, 11th ed. Lippincott Wiliams and Wilkins. Philadelphia. 3. Mohr, W. (2003). Johnson's psychiatric-mental health nursing, 5h ed. Lippincott Williams and Wilkins. Philadelphia. 4. Schull, P. (2010) Nursing spectrum drug handbook. Mc Graw Hill. 5. Videbeck, S. (2008). Psychiatric-mental health nursing, 4th ed. Lippincott Williams and Wilkins. China.

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City

Vision WVSU as one of the top universities in Southeast Asia. Mission To produce globally competitive individuals who are life-long learners.

Process Recording 4
Clinical Rotation: Psychiatric Ward

Submitted by: Pauline Joy C. Bacrang Jemar Harold G. Jison Jeahly M. Maquilang Ma. Terence Eulalie L. Subade Keith S. Subong BSN 3D RLE Group 4

Submitted to: Prof. Besie A. Duran, R.N.

Clinical Instructor