A. INTRODUCTION 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 Hospital and Medical Center). The group had encountered several common psychiatric disorders like the different types of schizophrenia and bipolar disorders. The group had chosen to study Bipolar Affective Disorder, current episode, manic with psychotic disorder. The group had chosen this type of disorder 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 disorder causes symptoms of depression and mania at the same time. 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 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 one’s abilities or powers, sleeping less but feeling extremely energetic, talking so rapidly, racing thoughts, jumping quickly from one idea to the next, highly distractible, impaired judgement and impulsiveness, acting recklessly without thinking about the consequences and lastly in severe cases, delusions and hallucinations may appear. If the client is under depressive, the common signs and symptoms 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. PATIENT’S PROFILE Name: Age: Birthday: Civil Status: Address: Religion: Nationality: Date of Admission: Time of Admission: Mr. I.E.R 56 years old July 4, 1953 Married Km8 Asin road, Tuba, Benguet Roman Catholic Filipino June 11, 2010 7:35 PM 1
Admitting Diagnosis: Current
Episode, Manic with Psychotic Disorder C. ASSESSMENT 1. Psychiatric History/Developmental 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. Basically, he had a good childhood experience as claimed. During his school age, he remembered that he does not participate in school activities and seldom mingle with his classmates. He further claimed that he is respectful to elders especially to his parents and grandparents. During his high school years, he experienced being involved with fist fights with the bullies. He remembered he was never separated from his family and was able to finish his degree 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 Arabia and work as a mechanical 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.
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. History of Present Illness The patient could remember that his mother told him that when he was sick with chickenpox and measles, he had high fever 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 more female friends than boys. At the age of 15, after he graduated from high school, he then have 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 to finish his chosen field of mechanical engineering. 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 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 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
In the case of our patient there was no mental illness in the family. His friends were not visiting him anymore and vice versa. and around that time he was observed to be normal again. praying on the road. He had optimistic ideas and plans were expressed. the son called their relatives and asked help from the nearby police station to get the patient..v. The patient was seen half naked. After he went to Balatoc Mines. The wife then went back to Saudi and after sometime the patient resumed his usual activities of digging around their house. Afterwards. and would walk around the house to and fro and he would utter incoherent words. So. Since then. the son introduced himself. high. but the patient wouldn’t forget his position in the family and would do household chores and would act accordingly. the patient would dig around their backyard and was preoccupied with doing unnecessary things. 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. One day prior to admission. He was helpful with doing house chores but noticed that he had lost his social life. He claimed that the old woman manipulated him to do it. Five days prior to admission. The time he was firstly observed with manifestations of the disorder the patient was into treasure hunting. This was extreme since the patient lost contact with reality and started to believe strange things. For his other siblings. P. hyperactive and irritable. excited. the patient felt abnormally good. he was only diagnosed with hypertension before admission at the Psychiatric Hospital. the patient came close to him saying. (their neighbor whom he always had an argument with). The patient developed symptoms of hallucination and delusion.that he was really close to his sister. This was accompanied by an elevated mood and he had reduced sleep. the patient stopped his treasure hunting activities and also claimed that he stopped seeing the old woman. the patient went to his room shouting over and over again. He claimed that he met an old woman that was dictating him what to do and where to hunt. The patient had a bag of stones and books saying he would go home to Zamboanga leaving the treasure to 4
. However. The patient started to mumble. who was the patient’s relative who worked in a mining company.. during the night when his son was watching t. Out of fear.F. “Sino ka… sino ka?. Soon after.B. the patient’s wife came home from Saudi. the patient kept on saying S. kissing the ground and saying that he is the savior. He had poor judgment and behaved in harmful ways which was dangerous. He was observed to be happy during those times.
BEHAVIOR 1. Patient has 5
3. His nails are trimmed and his beard and mustache are neatly shaved. He actively and openly answers queries being asked to him by the student nurses. refers wearing long sleeves but when it is hot. current episode.R. 56 years old was admitted and diagnosed with bipolar affective disorder.R. I. He usually stay on bed sitting or if not. he sometimes slouches during conversation with his legs and arms crossed and sometimes with his hands on his lap. Mr. I.R. swaying his feet while looking around the room. He was held and brought to the institution hence the admission. I. He sometimes cracks jokes that make the conversation lively. For 3 consecutive days of duty.. the patient is observed to brush his teeth before and after meals. Mental Status Examination A. has a noticeably proper cut hair and is well combed. 2. APPEARANCE The client appears to be well groomed.R. He usually prefers to talk with student nurses rather than to his co-patients inside the ward. manic with psychotic symptoms. Mr.R. is participative during discussion.his son. The client appeared as the stated age of 56 years old with visibly white hair and some noticeably wrinkles on his face. B. I. However. it was observed that he only took a bath on the third day then changed his clothes. Hence patient I. MANNER OF RELATING Mr. wears clothing appropriately depending on his mood and with the weather. PSYCHOMOTOR ACTIVITES The patient has a good posture. he wears the usual t-shirt along with his shorts or any available pants he has. Mr.
He has mild hand tremors observed. philosophy and history. May isa na akong apo. 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 talk in English. Maaga nakapag asawa. Mr.good posture. gait and station. I. However.R. 5. To explain further what are his thoughts. He used simple. SPEECH/LANGUAGE The client talks with normal rate. 4. THINKING During the conversation. concrete and easy to understand responses to the topics being discussed during the NPI (Nurse-Patient-Interaction). he becomes very sad with teary eyes. He was able to discuss recent events of the world and how these are predicted by previous events. when the topic is about the incident where he wasn’t able to visit his sister and dad’s burial. He elaborates his answers to questions asked and sometimes. stammering. He would use simple words to his co-patient while he uses more complex vocabularies to the health care providers. rhyming. he shares some topics to be discussed. Patient is able to adjust his choice of words depending on whom he is talking to. rhythm and intensity.. he feels very happy and is seen smiling. It was observed during the conversation that whenever the discussion deals with his wife finding time visiting him. C. DEVIATIONS There were no deviation like inventing. repetition of words and speeches in particular questions being asked by the student nurses noted. clanging of words. He also talks about his work and how was he as an employee when he works abroad. Tagalog and Ilokano fluently. 6. VOCABULARY The patient uses appropriate terms to use when conversing. 3. RELEVANCE/COHERENCE The client was able to answer relevantly and coherently.” There was no paranoid delusions observed from the client. It was also observed that he can easily find the right words to use when lost during conversation. However the patient was observe to avoid topics which concern on the reasons why he was brought to
. He talks about his family often and mentioned “Yung asawa ko nagwork sa Saudi at may isa akong anak.R. was able to discuss topics concerning religion. He speaks clearly and has good articulation of words. He was observed to walk straight. D. stated “okay naman pero minsan nadedepress”. I. MOOD and AFFECT Mr.
2. Mr.” He responded immediately “ Parang ganito sa situation ko. Siya yung una kong nakita nung pagpasok niyo. I.”He also claimed “Hypertension talaga problema ko. I am positive that this turmoil is to make me and my family stronger than before”. oo yung mataba.” 7
. Kasama ko ang asawa kong pupunta siguro. 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. In fact not only that. He can concentrate even if the ward seems so noisy. 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. para akong nakakulong ngayon pero there’s a purpose why I am here however taking that all into consideration. ABSTRACTION When the patient was asked of how did he understand the saying “A hard beginning maketh a good ending. He said “May ilog kasi doon malapit sa bahay namin. palagi kaming nabubuking kaya napapalo kami”.R. 1. time and self. INSIGHT When he was asked how can he sees himself as a father to his child. Naliligo kami ng walang paalam kaya pag-uwi namin. The patient is able to recall recent and past events in his personal history.the hospital. He can identify who brought him to the ward. he said “ Si Earl. is oriented to person. Hindi naman ako baliw. he simply said “ I have been a good father or a parent. E.”. Wala akong nakikita o nakakausap o naririnig na gaya ng naririnig at nakikita nung iba kong kasamahan dito”. place.The patient mentioned also “ Magbabakasyon muna ako sa Zamboanga pagnakalabas ako dito para makapagpahinga na din. 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. 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=___”. Malaking tao kasi.
. 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. When conversing with him he often focuses on his positive behavior like being a good husband to his wife and father to his son. He has tremors and claimed that “Ganito ‘to kasi side effect ng gamot”. F. which indicates that he is trying to elevate his self-esteem. PHYSICAL COMPLAINTS/PROBLEMS The client doesn’t have any physical deformities. G. SELF.3. which indicates a circulatory problem because of HPN.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. 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”. H. He is slow when walking because of aging.
Amorphous urates/PO4: Occasional
There is a presence of amorphous urates due to prolong refrigeration. Small amounts of protein or ketoacidosis tend to elevate results of the specific gravity.0 Specific Gravity: 1.
Color: yellow Transparency: Slightly Turbid Reaction/pH: 6.020 Protein: Neg WBC: None Epithelial Cells: Rare Bacteria: None
Normal Normal Normal Concentrated urine Normal Normal Normal Normal
The specific gravity of your urine is measured by using a urinometer. DIAGNOSTIC EXAMINATION
Date of Procedure
June 12. 2010
This test detects ion concentration of the urine.
. Knowing the specific gravity of your urine is very important because the number indicates whether you are hydrated or dehydrated.D. Specific gravity is an expression of the weight of a substance relative to the weight of an equal volume of water.
13.0 % 50.8/L MCH -32.0 x 109/L 0.2 % Mid % -8.0 pg 320 – 360 g/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
RDW-CV .100.2 x 1012/L 4.5 – 14.6 – 6.4 – 0.5 – 11.9 x 109/L Gran # -6.2% Gran % .0 .433/L MCV .65 Hgb .1 %
11. infection. and many other diseases.0 x 109/L 0.9 x 109/L 2.0 – 9.0 – 40.4. 2010
CBC (Complete Blood Count)
The CBC is used as a broad screening test to check for such disorders as anemia.4 pg MCHC -325 g/L
4.0 – 70.1– 0.0 – 31.0 % 135 -180 g/L 0.5 %
.0 x 109/L 20. It is actually a panel of tests that examines different parts of the blood.141 g/L HCT .65.99.0 – 7.0.4 x 109/L Lymph # -2.32 x 1012/L WBC -10.0/L 27.8 x 109/L Lymph % -26.54/L 78.
RBC .7 x 109/L Mid # -0.Date of Procedure
June 17.0 % 3.8 – 4.
15.0 – 11.6.6/L PLT .RDW-SD .0 – 17.8/L PDW .108 – 0.184 %
35 – 56/L
7.0/L 0.0/L 15.48.5/L PCT .0.adequate MPV .282 %
1 Separation from family members . Traumatic Experience
.He has the presence of the type A personality.3 Decrease Serotonin Level .As presented by Long term depression C.2 Increase Serotonin level . unable to express feelings.A decrease in serotonin levels indicates depression. Cultural Norms Because they have a close-knit family C. Biological Cause A.3 Living alone for several years . Because he has the three signs of mania which are Auditory Hallucinations.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. delusions and paranoia A.1 Increase Dopamine . He has the symptoms of depression like social withdrawal. which is inherently acquired thus he has poor IPR to others 2. Use of Defense Mechanism of the situation Ineffective use of Denial as manifested by unrealistic perception C.Being alone and independent in an area that is unfamiliar C. low selfesteem and persistent sadness B. Genetic Predisposition B.1 Being Shy . Presented by poor IPR to other people. lack of close friends.It is according to Freud’s Psycho-social theory. isolates self. PSYCHOPATHOLOGY 1. Psychosocial Causes A.An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder. Development of Mistrust . social withdrawal B.As manifested by anxiety and fear D.E.2 Death of his Sister . Neurotransmitter Alteration A.
Mistrust Poor IPR to other people -Unable to express feelings Manic Signs and Symptoms: -Agitation Hyperactivity -Racing Thoughts -Delusions of Grandeur -Illusions Depressive Signs and Symptoms: -Insomnia -Persistent sadness -Social withdrawal -Low selfesteem -Difficulty Concentrating -Lack of close friends -Isolates self -Social withdrawal Traumatic Experience Cultural norms Close-knit family Psychosocial Causes
Dopami ne Over production of dopamine causes nerve circuits to misfire and create a split state in the Auditory hallucinatio ns Delusion s Paranoia
Increas e se
Type A personality
Separation from family
Death of his sister
Living alone for several years
Chronic Low Selfesteem Use of defense mechanism Denial Ineffective Unrealistic perception of the situation Causing disturbed visual field and postural imbalance
Long term depression Stress Activation of the SNS (fight or flight response) Blood Pressure. Manic with Psychotic Disorder
Risk for injury Poor compliance to treatment regimen -medicine Possible separation to wife
Risk for relapsed episode 13
. respiration Altered cardiovascu lar status
Bipolar Affective Disorder. Current Episode.PSYCHODYNAMICS Neurotransmitter Alteration Genetic Predisposition Being shy Development vs. pulse rate.
coronary artery disease
>Essential hypertension. DRUG STUDY
Generic name Trade name Amlodipine besylate
Dosage Start and Completion of Medication Dosage: 10 mg 1 tab OD Date started: 06/17/10
Mechanism of Action
Calcium channel blocker Antianginal drug Antihyperten sive
Blocks the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. pronounced dizziness or constipation. and output while adjusting drug to therapeutic dose. lightheadedness. > tell the client to report irregular heartbeat. arrhythmias DERMATOL OGIC: Flush. >Instruct client to take with meals if stomach upset occurs. blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. Since calcium is important in muscle contraction.
>Monitor the patient’s BP. >instruct client to swallow the tablet whole with or without food as directed by the physician. shortness of breath. or in combination with other agents
CNS: dizziness. cardiac rhythm. fatigue CV: peripheral edema. rash GI: nausea.F. swelling of hands and feet. abdominal discomfort.
Generic name Trade name
Dosage Start and Completion of Medication
Mechanism of Action
nausea GU: impotence. when discontinuing clonidine. dizziness CV: CHF. sedation.Clonidine Antihyperten hydrochloride sive Catapres
Dosage: 75 mg. > tell the patient that discontinuing abruptly. hypertension usually returns within 48 hours. constipation. 1 tab SL fo BP ≥ 140/90 Date started: 06/14/10
Stimulates CNS alpha2 adrenergic receptors. diminished libido
>monitor BP carefully.
CNS: drowsiness. The drug should be put under the tongue. orthostatic hypotension. decreased sexual activity. >Do not discontinue drug unless so instructed. tachycardia. inhibits sympathetic cardioaccelerator and vasoconstrictor centres. >Take the drug exactly as prescribed. palpitations GI: dry mouth. life threatening adverse effects may occur.
Dosage Start and Completion
Mechanism of Action
. and decreases sympathetic outflow from CNS.
maintain adequate fluid intake. CNS: lethargy. diarrhea GU: pyloria >Give drug with food or milk after meals. muscle weakness GI: nausea. but not serotonin from stimulated neurons. >Monitor clinical status closely >take this drug exactly as prescribed.milk >Instruct client to open mouth and lift tongue to check for the drugs.Trade name Lithium carbonate Antimanic drug
of Medication Dosage: 450 mg 1 tab BID Date started: 06/12/10 Alters sodium transport in nerve and muscle cells.
. >tell the patient to eat a normal diet with a normal salt intake. after meals or with food or . Treatment of manic episodes of manicdepressive illness. inhibits release of norepinephrine and dopamine. slurre d speech. slightly increases intraneural stone of cathecolamines. vomiting. decrease intraneuronal content of second messengers and may the by selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic state.
. >Do not dilute this with coffee.the medication may lose effectiveness. As a result. >Instruct client to open mouth and lift tongue to check for the drugs. salivation.Generic name Trade name Haloperidol haldol
Dosage Start and Completion of Medication Dosage: 10 mg deep IMx 3 doses PRN for severe psychotic agitation. If dizziness or drowsiness or vision changes occurs. insomnia. the nerves are not "activated" by
Management of manifestation of psychotic disorders. Date started: 06/11/2010
Mechanism of Action
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. tea. nasal congestion CV: hypotension hematologic : eosinophilia.
CNS: drowsiness. leukopenia
>Take the drug with food or exactly as prescribed. >Instruct client to Avoid engaging in other dangerous activities. headache autonomic: drymouth. >Do not stop taking this drug suddenly without consulting your doctor. It blocks receptors for the neurotransmitter s (specifically the dopamine and serotonin type 2 receptors) on the nerves. colas or apple juice .
avoid excessive dosage >Instruct client to open mouth and lift tongue to check for the drugs. dysuria thrombocytope nia
>Administer with food if GI upset occurs. 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). tremors. >Monitor patient’s response. x 3 doses PRN for severe psychotic agitation with BP precaution Date started: 06/11/10
Mechanism of Action
Antihistamin e Antiparkinso nian
Competitively blocks the effects of histamine at H1-receptor sites. for milder form of disorders in other age groups. bradycardia GI: epigastric distress. >tell the client to report difficulty of breathing. palpitation. sedation. irregular
. dizziness CV: hypotension. GU: urinary frequency. IM q 1 hr. and in combination of
CNS: drowsiness.the neurotransmitter s released by other nerves
Generic name Trade name diphenhydra mine Benadryl
Dosage Start and Completion of Medication Dosage: 50 mg. >take as prescribed. unusual bleeding or brusing. anorexia. in the elderly tolerant of the more potent agens.
>Monitor BP and pulse prior to and frequently during the period of dosage adjustment. GU: urinary retention
>Assess mental status prior to and periodically during therapy. 1 tab in HS Date Started: 06/12/10
Block dopamine receptors in the brain.centrally Hepatic: acting hemolytic anticholinergic anemia antiparkinsonia n drugs. control of manic phase of manic depressive illness. >Instruct client to open mouth and lift tongue to check for
. dry mouth.
CNS: neuroleptic malignant syndrome.
heart beat. CV: hypotension EENT: blurred vision. ½ tab AM. GI: constipation. anorexia.
Generic name Trade name Chlorpromazi ne Thorazine
Dosage Start and Completion of Medication
Mechanism of Action
Antipsychoti Dosage: cs 200 mg. also alter dopamine release and turnover.
Management of manifestation of psychotic disorders. >Observe patient carefully when administering medication. sedation.
the drugs. dilatation of
>Give with meals if GI upset occurs. arterioschleroti c. 1 tab OD Date started: 06/12/10
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
Adjunct in the therapy of parkinsonism (post encephalitic. witih remaining doses evenly spaced throughout the day. >Take the drug as prescribed. hallucination CV: tachycardia. and idiopathic types)
CNS: disorientation. >Instruct client to open mouth and lift tongue to check for the drugs.
Generic name Trade name
Dosage Start and Completio n of Medication
Mechanism of Action
antiparkinson Dosage: ian 2 mg. constipation. palpitations. confusion. give before meals for clients who have dry mouth. urticaria GI: dry mouth. give after meals if drooling or vomiting occurs. >Advice patient to take medication as missed doses as soon as remembered. > tell patient to report
. memory loss. hypotension Dermatologic : rash.
rapid pounding of the heart.
difficult or painful urination. confusion. eye pain or rash. constipation. and to lesser extent.patient. akinesia and tremor characterizing parkinsonism.
. Reduces severity of rigidity.
or even getting on that roller coaster with their kids. 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. How one responds to such stressors depends on the person’s coping resources. 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. Without the self esteem to believe they can accomplish something new. breathing and circulation concept states that circulation should always be the third to be assessed. illness. social support networks. fear keeps the sufferer from asking for that promotion. This obstruction creates a resistance to ejection and increased pressure in the left ventricle. everyday life includes its share of stressors and demands. And if the heart doesn’t work normally.G. problem-solving skills. and professional role responsibilities to major life events such as divorce. personal health and energy. ranging from family. work. going on a date with the person they're attracted to. Socio-cultural and religious factors may influence how people view and handle their
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
. the other systems and their functions will be affected. and material resources. PRIORITIZATION
RANKING NURSING DIAGNOSIS/ PROBLEMS JUSTIFICATION
Altered cardiovascular status related to increase pressure secondary to Hypertension
Airway. or dwelling on mistakes that they've made in the past. Such resources can include optimistic beliefs. and the death of loved ones. For most persons. that they fail to enjoy the here and now moments in life.
We ranked this as our second priority because People with chronic low self esteem issues often spend more time worrying about the future.
majority of psychiatric clients are r/t poor compliance to medical treatment
. Vulnerable populations such as elderly patients. those in adverse socioeconomic situations. If this potential problem is not given immediate attention. 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. Risk for injury is one of the most common complications of hypertension that is why it is the prioritized potential problem. this may cause a more serious problem to the patient. or those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors.problems.
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
We ranked this as the least priority because the chances of having relapse episode are about 40% is needs are not satisfied.
patient was able to demonstrate understanding and techniques to prevent increase of BP
LTO: Goal met. NURSING CARE PLAN NCP ACTUAL #1: ALTERED CARDIOVASCULAR STATUS R/T INCREASE PRESSURE SECONDARY TO HYPERTENSION ASSESSMENT S>” Problema ko tong BP ko. low sodium >Reiterated religious taking of medication >Encouraged rest periods as necessary RATIONALE >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 >To provide safety >To maximize sleep periods that provide good energy source >Immediate interventions will be done >To maintain normal BP >To help regulate BP >To prevent sudden increase of BP 25 EVALUATION STO: Goal met. the Blood pressure will be maintained at 130/90 from 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. Proper Deep breathing exercises NURSING INTERVENTION Dx: >Monitored vital signs especially BP >Assessed contributory factors of increase BP Tx: >Assisted in getting up slowly from bed to bedside or from supine to moderate high back rest >Assisted in going to the comfort room or using the commode if necessary >Promoted adequate rest by decreasing stimuli.H. Waking up slowly on bed and resting before walking b. patient’s Bp was maintained at 130/90
LTO: After 3 days of nursing intervention. During admission until the third day patient has a fluctuating BP of 130/100 to 150/100. Source: Brunner and Suddarth’s MedicalSurgical Nursing 7th edition GOALS AND OBJECTIVES STO: After 1 hour of health teaching. patient will be able to demonstrate understanding of techniques and ways to prevent further increase of blood pressure like: a. tumataas” Bp150/100 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 EXPLANATION OF THE PROBLEM Patient has a history of hypertension. chest pain or any discomfort >Emphasized importance of diet low fat. providing quiet environment and scheduling activities Edx: >Instructed to report shortness of breath.
To will be able to increase compensate to his self-esteem through: shortcomings he made use himself by doing household a. taking charge for all will be able to verbalize their expenses. Reinforcing the in turn inadequate for him personal strengths and which led him to have a positive perceptions chronic low self-esteem. ICI wife is a nurse LTO: After 3 days of working in Saudi. Giving positive chores and becoming feedback responsible in taking care of his son but these were not b. and provide opportunities for their expression and recognition >Noted non-verbal behavior >Used positive messages rather than
The client was able to increase selfesteem through giving positive feedback. Focusing topics enough to show that he is such as on the client’s useful and not enough to accomplishments in life show his worth as father. was able to appreciate his accomplishments in life and was able to identify his strengths and positive perceptions
. the client family. To assist client to develop internal sense of selfesteem Supporting a 26
> Assessed existing strengths and coping abilities. appropriate nursing He felt shame and guilty to interventions. the client his present situation.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 GOALS AND PROBLEM OBJECTIVES Mr. their gender Mr. She is the nursing one who’s working for their interventions. All of the things that he did were c. providing understanding of support for their family and individual’s role in the taking already the seat as the society regardless of bread winner of their family. that the client identifies
INTERVENTION PDx > Established Rapport
>Assessed presence of negative attitude and or self talk
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. ICI felt so bad with that because he should be the one STO: After 8 hours of who’s doing all of that stuff.
until he or she feels secure that the group members will be accepting. Tx>Maintained therapeutic communication > Rendered positive feedback
www. Caregiver may need to accompany client at first.medscape.appraisal AEB negative feedback about self
client’s beliefs and self-rejection and helping them cope can affect selfesteem To facilitate trust during interaction
>Focused on accomplishments Edx> Encouraged participation in group activities. express to client
To increase selfesteem To lift self-esteem
Positive feedback from group members will increase selfesteem
The ability to communicate effectively with 27
. If verbalizations are not understandable. regardless of limitations in verbal communication >Encouraged client's attempts to communicate.
. It may be necessary to reorient client frequently
others may enhance selfesteem
>Reinforced the personal strengths and positive perceptions that the client identifies.what you think he or she intended to say. >Gave reinforcement for progress noted.
Clients with low self-esteem need to have their existence and value confirmed Give reinforcement for progress noted.
questions. > Client may misinterpret and believe references are to him. >Listened attentively to what the patient says. A> Ineffective denial related to inability to tolerate the consequences of known disorder.com/cs/bpbasics/ a/what_causes_bp.about.
O> Does not mingle to other roommates. thought to be the main element in appropriate nursing therapeutic regimen to feelings Hindi ako baliw. > Positive reinforcement will help the patient change his mood like sadness. >Only interacts to nurses. the development of bipolar intervention the congruent with Wala naman patient will verbalize >Assessed ability to behavior. Tx> Minimized discussion of negative personal problems within clients hearing.htm
> knowing the trigger factors could help you determine what to do if the patient shows. >help the client relieve stress and you will be able to know how to be therapeutic
psychological needs as evidence by appropriate expression of feelings.
. patient meet wife is abroad.
> Assessed triggering factor that may stop your client from talking to you.” A symptom of bipolar that contributes for the patient to deny his known illness is exaggerated self-esteem. >Always stays in his bed.
Edx> Encouraged patient to continue verbalizing thoughts and feelings.
nursing interventions the patient will meet psychological needs as evidence by appropriate expression of feelings. 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.NCP ACTUAL #3: INEFFECTIVE DENIAL R/T INABILITY TO TOLERATE THE CONSEQUENCES OF KNOWN DISORDER ASSESMENT EXPLANATION OF THE GOALS AND INTERVENTIONS RATIONALE PROBLEM OBJECTIVES
S>” Hypertension P/Dx> Observed > Shows if the patient STO: SECONDARY and One cause FOR INJURY R/T is STO: naman NCP POTENTIAL #1: RISKof bipolar disorder IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMANDcould interact TO HYPERTENSION if the talaga ang behavioral responses Goal met stressful life events these are After 1-2 hours of interested to patient was able problema ko. > Showing interest while the patient talks boost his confidence to share more.
http://bipolar. disorder. family members and student nurses. kasamahan ko dito. doctors. 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. but limitations should be set so that you won’t be giving negative result to the behavior of the client. >Provided positive reinforcement.
Interventions Dx> Monitored and recorded vital signs.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. gender. the patient will be able to demonstrate behaviors. 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. the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury.
Goal met if the patient is able to demonstrate behaviors. level of cognition or competence Tx> Provided information regarding disease or conditions that may result in increased risk of injury > Assisted client to develop plan for activity and exercises within individual ability > Provided diversional activities.
Explanation of the Problem The client is then experiencing hypertension that causes imbalance between the oxygen supply and demand. decreased concentration and easy fatigability Source: Brunner and Suddarth’s MedicalSurgical Nursing 7th edition
Objectives STO: After 8 hours of nursing intervetions. avoiding overstimulation and understimulation
Rationale of the Interventions > this will serve as baseline data > sometimes these are not recognized by the clients.
. sluggishness and worthlessnesss
Expected Outcome Goal met if the patient is able to verbalize understanding of individual factors that contribute to possibility of injury. such as side effects or interactions of medications > Noted client’s age. This imbalance causes alteration in the brain cell functioning leading to decreased perceptual function as manifested by dizziness when standing suddenly. lifestyle changes to reduce risk factors and protect self from injury. 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.
LTO: After 1 to 2 days of nursing interventions. decision-making ability. developmental stage. lifestyle changes to reduce risk factors and protect self from injury. noting blood pressure > Noted treatmentrelated factors.
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
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. LTO > Patient was able to understand about his treatment by taking his medications as scheduled and informing any changes of behaviors. > Invited client to do activities. > Listened to feelings that he expresses. > promotes sense of trust. Completed his education till college level and later got married and have children. > encourages continuation of treatment. > builds trust. > to determine contributing factors. Nursing Interventions Dx > Assessed client’s perception of self and noted use of defense mechanisms. > Returns back to his usual self when the wife is back home. Objectives STO > After 6-8 hours of nursing intervention patient is able to show signs coping measures. Wife had gone back to Iran to work. leaving the husband and son in Philippines. > Assessed clients coping behaviors already present. > Gave positive reinforcement for Rationales > to determine causative factors > to determine signs of relapse. > Maintained straight forward communication. 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. > decreases defense 33 Evaluation STO > Patient was able to demonstrate coping mechanism as evidenced by relaxed posture and calm behavior. allowing patient to discuss feelings openly. Tx > Developed therapeutic nurse-patient relationship. > offer emotional support and understanding. Then husband start acting strange with interest of treasure hunting and going outside naked.
. > to avoid reinforcing manipulative behavior. Came back to the Philippines and continue working for his family. > for positive distraction. But returns normal when wife comes back home. enhancing therapeutic relationship. Went to Iran and worked abroad to help support his family. LTO > After 1-2 hours of nursing intervention patient is able to understand the importance of his treatment and verbalize his feelings. > Being truthful when giving information and dealing with patient. > Reviewed laboratory and medication chart.
> to prevent relapse.
response. > Explained to client symptoms improve gradually and not immediately. > Educated client to not stop on medication without physician’s order. > to make adjustments in the treatment. Edx > Encouraged client to get adequate sleep. >Advised client to report mood changes immediately. > to help to deal with stress. > to understand that it is a long term treatment.
. > Maintained calm. > to prevent fatigue. matter of fact.client’s efforts. nonjudgmental attitude. > Instructed client to take medication as ordered.
I. reading. Cleaning. reorganizing.
DISCHARGE PLAN DIET AND NUTRITION ACTIVITY Mental health professionals try to steer people away from sedentary activities such as TV where the mind and body are not fully engaged. Creative activities like occupational therapy. 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 Bipolar 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
Instructed client to eat frequent small meals Instructed to have high protein. 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. or raising goldfish could all be great indoor activities. high carbohydrate diet for energy
the group concluded that this disorder has different symptoms as compared to the other psychiatric disorders.J. the cycles of bipolar disorder last for days. This study makes us student nurses more competent and gained more confidence in handling patients with Bipolar Disorder. Interaction with the patient for more than 3 days is not enough to cover from his childhood up to now. in the making of this case study and understanding how this disorder affects a person through appreciating it’s pathophysiology. Since the client has Bipolar Disorder. months or even a year. sleep very little and are hyperactive. More than just a fleeting good or bad mood swings.
CONCLUSIONS AND RECOMMENDATIONS Bipolar disorder causes serious shifts in mood. We should interact with the patient more and more to know about his history and different traumas that he encountered. People experiencing a manic episode often talk a mile a minute. Therefore. weeks.
. We should also be well knowledgeable to psychiatric disorders prior to duty to enhance more our interventions and interactions. energy. Unlike ordinary mood swings. thinking and behavior from the highs of mania on one extreme to the lows depression on the other. Well preparation to go on duty at the area should be done before the actual duty by conducting self awareness test. the mood changes bipolar disorder is so intense that they interfere with your ability to function.