Jam Mikka G.

Rodriguez
NCM 105 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

ACTIVITY #3 -

CASE STUDY (1)

You are spending time with Mr. Mac Howdy, who is being given a workup for depression. He avoids eye contact,
he slouches in his seat, and his expression appears blank, but sad. Mr. Mac Howdy has suffered from numerous bouts of
major depression in the past and says to you, “This will be my last depression. I will never go through this
again.”

A. If safety is the first concern, what are the appropriate questions to ask Mr. Mac Howdy at this time?
- Are you thinking of harming yourself?
- Do you have a plan to harm yourself?

B. Give an example of the kinds of signs and symptoms you might find when you assess a patient with depression in
terms of behaviors, thought processes, activities of daily living, and ability to function at work and at home?
- Feelings of sadness, the blues, anger, anxiety, powerlessness, hopelessness.
- Crying, agitation, withdrawal, slowed physical movements, slumped posture, slow speech, social isolation.
- Difficulty thinking of anything other than disappointment, preoccupation with loss, self blame, slowed thinking
process, difficulty concentrating, portraying negativism and pessimism, suicidal ideation.
- Tired and restless, anorexia or overeating, insomnia or sleeping too much, may have physical pain.

C. Mr. Mac Howdy tells you that he has tried every medication there is but that none have worked. He asks you about the
herb St. John’s Wort. What is some information he should have about its effectiveness for severe depression, its
interactions with other antidepressants, and its regulatory status?
- Generally recognized as a safe and effective way of treating depression but St. John’s Wort isn’t consistently
effective for depression. Do not use it to replace conventional care or to postpone seeing your health
care provider.
- May not be as effective in severe depression.
- Should not be taken with other psycho active meds.
- St. John’s Wort limits the effectiveness of many prescription medicines.
- Combining St. John’s wort and certain antidepressants can lead to a potentially life-threatening increase in your
body’s levels of serotonin, a chemical produced by nerve cells.
- St. John's Wort is classified by the U.S. Food and Drug Administration (FDA) as a dietary supplement, not a
drug. The FDA does not test it for safety and effectiveness, although it can take action if there is a safety issue.
The FDA has not evaluated St. John's Wort as a treatment for any medical condition.

D. What might be some somatic options for a person who is resistant to antidepressant medications?
- Cognitive behavioural therapy has been shown to be as effective at pharmacological treatments.
- ECT: Induction of grand mal seizure through the application of electrical current to the brain.
- Transcranial Magnetic Stimulation: stimulates nerve cells in the brain by using short pulses of magnetic energy.
This does not result in seizure activity.
- Light Therapy: Related to the presence of melatonin. It is administered by a light box. Individual sits in front of
with eyes (not looking straight in) for about 10-15 minutes working up to 45 minutes.

E. Mr. Mac Howdy asks what causes depression. In simple terms, how might you respond to his query?
- Depression is caused by a complex interaction between biological (neurotransmitter levels), psychological
(maladaptive schemas), and social factors.
- Genetic factors.
- Physiologic factors (neurochemical imbalance and hormonal influences).
- Psychological factors ( conflict between wanting to be loved and fear of rejection, anger turned inward, learned
helplessness and feminist theory).
Jam Mikka G. Rodriguez
F. Mr. Mac Howdy tells you that he has never tried therapy because he thinks it is for babies. What information could you
give him about various therapeutic modalities that have proven effective for some other depressed patients?
- Individual psychotherapy:
Phase I: Client is assessed to determine the extent of illness. Also determine if the client would benefit
from therapy in conjunction with antidepressant medication.
Phase II: Focuses on helping the client resolve complicated grief reactions.
Phase III: Therapeutic alliance is terminated.
- Group Therapy: Offer an avenue of support for depressed individual. Peer lead and not meant to be a substitute
for professional therapy.
- Family Therapy: Objectives are to resolve issues to initiate or restore adaptive family functioning.
- Cognitive Therapy: Individual is taught to control thought distortions that are considered to be afactor in the
development and maintenance of mood disorders.

G. When you are teaching Ms. Mac Howdy about her SSRI sertraline (Zoloft), she asks you, “What makes this such a
good drug?”
A. What are some of the positive attributes of SSRIs? What is one of the most serious, although rare, side effects
of the SSRIs?
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. They
can ease symptoms of moderate to severe depression, are relatively safe and typically cause fewer side effects
than other types of antidepressants do. It blocks the reabsorption (reuptake) of serotonin into neurons. This makes
more serotonin available to improve transmission of messages between neurons.One of the most serious side
effect is hyponatremia.

Side Effects:

 feeling agitated, shaky or anxious

 feeling or being sick
 indigestion
 diarrhoea or constipation
 loss of appetite and weight loss
 dizziness
 blurred vision
 dry mouth
 excessive sweating
 sleeping problems (insomnia) or drowsiness
 headaches
 low sex drive
 difficulty achieving orgasm during sex or masturbation
 in men, difficulty obtaining or maintaining an erection (erectile dysfunction)

B. Devise a teaching plan (on medication) for Ms. Mac Howdy.

 Take your medicine at the same time and as prescribed dosage .

 You should not stop taking the medication unless you consulted it to your health care provider

 Avoid all other medications including OTC (over the counter) and complementary drugs without checking
with their prescriber first;
Jam Mikka G. Rodriguez
 inform the prescriber of all current medications, medical conditions and allergies;

 Take your medicine with meals to minimize GI distress.

 Make sure the patient understands their medications as you administer them. Quiz them on the actions and
side effects.

 Explain to the patient how this will help them to control their chronic or acute disease and what outcomes to
expect. Further you need to explore with the patient whether these medications will be necessary long term?
Do they understand how and when to refill medications? If this is the first time a patient has had an acute
illness he may not know that he needs to refill a medication. That process may be completely foreign to him.

 Provide patients with information about signs and symptoms to report to his physician and ensure that he
knows to do this timely and not wait for another crisis to act.

CASE STUDY (2)

Kioshi Sung is taken into the emergency department after threatening in a loud voice to, “Blow up the world to savethe
poor, and many more, where’s the door? No more, no more. Let me loose.” He had attacked a bartender who would not
give him any more to drink. He has not eaten or slept for more than 1 week and only takes sips of fluids when offered. He
talks nonstop, moving constantly, flailing his arms, and bumping into objects as he walks rapidly.

A. Identify Mr. Sung’s immediate needs (in terms of a nursing diagnosis). Describe the interventions you would plan for
his physiological safety and his milieu (safe environment).
- The priority nursing diagnosis of the patient is fluid deficit volume and imbalanced nutrition or elimination
as well as disturbed sleep pattern.
 Encourage the patient to eat and offer frequent high- calorie protien , drinks and finger foods.(sandwich and
fruits)
 Monitor intake, output and vital signs

Physiological safety:
 Maintain the low level of stimuli in patient’s environment (e.g away from bright lights,loud noises and
people)
 Provide structured solitary activities with the nurse aid
 Provide frequent rest period

B. Discuss the most appropriate communication techniques and approaches for Mr. Sung at this time. Give examples of
what you would say and how you would say it.
- What will you do to handle this situation?
- What would you do to make your anger harmlessly?

C. What possible medications would Mr. Sung most likely be given immediately? Long term?
- Antimanic medications with is Lithium has a narrow therapeutic index and it is use for urgent
situation.Lithiummay also be used to treat depression as well as being a long-term mood stabiliser. AEDs
such as carbamazepine and valproic acid are useful , especially in treating people with disease refractory to
lithium therapy. Carbazepine seems to work better in patients with the rapid cycling and in severely paranoid
and anger patient with mania behavior and mixed bipolar disorder. Newer AEDs are also useful in treating
patients who need rapid de-esclation and do not respond to other treatment approaches.

D. Write a medication treatment plan for Mr. Sung and his family.
Keep taking your drugs even if your mood is stable. Don’t stop taking your drugs even if you feel better. To avoid
relapse, you need to take your medications on a regular basis.
Jam Mikka G. Rodriguez
Don’t expect your meds to solve all your problems. They can only help to reduce the symptoms of mania and
depression, but to feel better, it’s absolutely essential to keep a healthy lifestyle, which will ensure your good
mood. It includes the support of your friends and family, therapy and rest.

E. Describe at least four evidence-based therapeutic modalities for a bipolar patient.

Psychoeducation provides information on mental health to patients, teaches symptom recognition, and facilitates
development of individualized coping strategies for illness management (Zaretsky, Rizvi, & Parikh, 2007).
Psychoeducation generally consists of at least three sessions teaching patients how to use self-management tools,
such as self-care workbooks; educational videotapes addressing the diagnosis, course, treatment, and management
of bipolar disorder; and drafting individualized relapse prevention plans (Miklowitz et al., 2007).
The cognitive-behavioral therapy framework proposes a self-perpetuating cycle of reactions to cognitive and
affective symptoms that impede functioning and exacerbate the psychosocial problems and Stressors
characteristic of bipolar disorder (Basco, Ladd, Myers, & Tyler, 2007). The goal of cognitive behavioral therapy
is to target cognitive, behavioral, and affective changes in depression and mania and help the patient manage the
disorder by stopping the progression of episodes.
Family-focused treatment is an approach characterized by modules consisting of
psychoeducation,communication skills training, and problem-solving skills for illness management (Morris,
Miklowitz, & Waxmonsky, 2007). It may increase families' ability to provide structure, enhance adherence to
treatment, and delay or reduce the number of relapses (Morris, Miklowitz, & Waxmonsky).
Interpersonal and social rhythm therapy was developed by integrating standard elements of interpersonal
therapy with social rhythm therapy, a treatment approach that attempts to stabilize social and circadian rhythms
based on the hypothesis that "unstable or disrupted daily routines lead to circadian instability and affective
episodes in vulnerable individuals" (Zaretsky et al., 2007). it emphasizes the need for regular sleep/wake cycles
to keep moods stable, and clients are asked to keep detailed records of daily and nightly activities, levels of social
stimulation, sleep, and mood.

F. What symptoms would help you evaluate if a bipolar client was in hypomania, mania, or stream media?

Mania symptoms include:

 Abnormally and persistently elevated, expansive, or irritable mood

 Inflated self-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual or pressure to keep talking
 Flight of ideas or subjective experience that thoughts are racing
 Distractibility
 Increase in goal-directed activity or psychomotor agitation
 Excessive involvement in pleasurable activities that have a high potential for painful consequence

In order for the mood to be considered manic, these symptoms must cause “marked impairment infunctioningor
relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.” 

Hypomania, which like to call mania-light. All the crazy with half the impairment. It includes symptoms like:

 A distinct period of persistently elevated, expansive, or irritable mood

 Inflated self-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual or pressure to keep talking
 Flight of ideas or subjective experience that thoughts are racing
 Distractibility
 Increase in goal-directed activity or psychomotor agitation
Jam Mikka G. Rodriguez
 Excessive involvement in pleasurable activities that have a high potential for painful consequences

The mood must also be unusual for the individual and noticeable by others. And now the important part, “the
episode is not severe enough to cause marked impairment in... functioning, or to necessitate hospitalization, and
there are no psychotic features."

G. Name the most important interventions you would institute for each of the three phases of mania.

There are several phases in which bipolar disorder may be managed, the acute phase, the continuation phase, and the
maintenance phase. Prioritizing nursing interventions can be set according to the most immediate attention needed
for patient safety.

I. The acute phase focuses on injury prevention; therefore, the first intervention should prioritize the patient’s
physiological status.

 Demonstrate self-control with aid of staff or medication, as evidenced by absence of harm to others.
 Make no attempt at self-harm with aid of staff or medication, as evidenced by physical safety checked with
regularity throughout period of acute mania.

II. In the second phase which is the Continuation of Treatment the nursing intervention encourage patient to
attend psycho educational classes that discuss a variety topics and give directions to patients and families to help
prevent relapse about the knowledge of disease process, knowledge of early signs of relapse, knowledge of
medication, and the consequences of substance addiction for predicting future relapse. Encourage also the patient to
attend support groups of therapy such as cognitive behavioral therapy, interpersonal social rhythm therapy and
family focused therapy.
III.Maintaining the the medication and psychosocial therapies of the patient