LADYBELLE P.

GOTOTOS PSYCH CODE: 157

BSN3-SET1 APPLICATION WEEK 9
1. Identify a question that the nurse might ask to assess each of the following. (10 points)
QUESTIONS
1. ABSTRACT THINKING ABILTY - What do I mean when I say, 'Don't sweat the small stuff?
- Can you interpret these proverbs? “People who live in glass houses
should not throw stones.”
- What does the phrase “butterflies in the stomach” mean
- Pwede mo bang I- identify kung saan nabibilang ang mga sasabihin ko?
-Yellow and Blue
-Doctor and Nurses
-Apple and Orange
-Carrots and Cabage
- Mag kahanay ba ang Carrots at Apple?
2. INSIGHT - Can you describe to me your strength and weaknesses?
- What brings you here today?
- What is your understanding of your problems?
- Do you think your thoughts and moods are abnormal?
3. SELF CONCEPT - How do you feel about yourself?
- Anong characteristics ng sarili mo ang gusto mo? at ano yung mga
gusto mong baguhin?

4. JUDGEMENT - What would you do if you found a stamped letter on the sidewalk?
- Pag nasa bahay ka at naka kita ka ng sunog, ano ang gagawin mo?
5. MOOD - How are your spirits?
- How would you describe your mood?
- Have you felt discouraged lately?
- Have you felt angry/irritable/on edge lately?
- Have you felt energized/high/out of control lately?
6. ORIENTATION - What is your name?
- How old are you
- Where are you today?
- What is the date today?
LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9
- What time is it?
- What just happened to you?
 LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9
2. Ms. Catie Holmes is a 32 y.o female who appears her stated age. Appearance is remarkable for wearing revealing and likely
designer clothes with excessive makeup. Behavior is hyperactive and agitated at times. Speech is pressured and with an increased rate,
often loud. Mood is described as ‘happy and on top of the world’ and affect is elevated and euphoric. Not appropriate to situation. It is
also irritable in parts and quite labile. Thought process is disorganized with apparent flight of ideas connected to grandiose delusional
themes. There is no suicidal or homicidal ideation. Thought content has grandiose delusions. Perception appears normal. Insight is
poor and Judgment is quite poor – wants to fly to Milan in this state which can lead to unfortunate outcomes. Also, pt. is exercising
poor judgment with finances.
Please Make a Nursing Care Plan using this situation (20 Points)

NURSING CARE PLAN FOR PT. WITH MANIA DISORDER

ASSESSMENTS DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Subjective data: Risk for injury After 2-5 hours of INTERVENTION RATIONALE After 3 days of nursing
 Patient related to nursing intervention the Independent interventions the clients was
verbalized hyperactivity and patient will be: able to:
her desire to agitation, as *Develop caring *To build trust and make
fly to Milan evidenced by a. Free of rapport with client. the patient comfortable a. Remains free of injury
with her impaired insight dangerous levels with you during inpatient hospital
present state. and judgment. of hyperactive stay.
(Poor motor behavior *Providing for safety. *A primary nursing b. He displays a calming
judgement) with the aid of Develop caring rapport energy level and his
 Pt also medications and with client. thoughts gradually
mentioned nursing return to a reality base
about poor interventions. responsibility is to within 72 hours.
judgement b. Maintained and provide a safe c. Client is beginning to
with manage level of environment for client and talk about her situation
finances. agitation. others; for clients who and is expressing
 Pt also c. Not cause harm feel out of control, the appropriate feelings of
describe her to self or others *Providing therapeutic nurse must establish sadness and anger
mood as d. Experience no communication. external controls related to his loss and
‘happy and physical injury. emphatically and non- alteration in status.
on top of the e. Remain safe. judgementally. d. Demonstrate coping
 LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9
world’ f. Demonstrate techniques.
 According to coping * Clients with mania have e. Identify appropriate
the patient techniques. short attention spans, so actions for managing
she has no g. Identify the nurse uses simple, emotions.
suicidal or appropriate clear sentences when f. Recognize thoughts that
homicidal actions for communicating; they may are not based in reality
ideation. managing not be able to handle a lot and intervene to stop
*Promoting
emotions. of information at once, so their progression
appropriate behavior.
Objective data: h. Recognize the nurse breaks
 Appearance: thoughts that are information into many
wearing of not based in small segments.
revealing reality and
and likely intervene to stop * The nurse can direct
designer their their need for movement
clothes with progression. *Have patient write into socially acceptable,
excessive name periodically; large motor activities such
makeup. keep this record for as arranging chairs for a
 Behavior: comparison and report community meeting or
hyperactive differences. walking
and agitated.
 Pressured *These are important
speech * Maintain a pleasant measures to prevent
and quiet environment further deterioration and
 Increase rate
and approach patient maximize level of
of
in a slow and calm function.
talkativeness
manner.
 Loud voice
 Affect: * Patient may respond
elevated and *Present reality with anxious or
euphoric concisely and briefly aggressive behaviors if
 Irritable in and do not challenge startled or overstimulated.
parts and illogical thinking.
quite labile Avoid vague or
 Disorganized evasive remarks.
 LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9
thought *Delusional patients are
process extremely sensitive about
 Thought *Be consistent in others and can recognize
content has setting expectations, insincerity. Evasive
grandiose enforcing rules, and so comments or hesitation
delusions forth. reinforces mistrust or
 Poor insight delusions.
and *Reduce provocative
Judgement stimuli, negative * Clear, consistent limits
criticism, arguments, provide a secure structure
and confrontations. for the patient.

*Use touch cautiously,

particularly if *This is to avoid
thoughts reveal ideas triggering fight/flight
of persecution. responses.

*Engage the patient in * Patients who are

one-to-one activities suspicious may perceive
at first, then activities touch as threatening and
in small groups, and may respond with
gradually activities in aggression.
larger groups.

*Encourage patient to *A distrustful patient can

verbalize true feelings. best deal with one person
Avoid becoming initially. Gradual
defensive when angry introduction of others
feelings are directed at when the patient can
him or her. tolerate is less
threatening.
* Assist in identifying
LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9
ongoing treatment * Verbalization of
needs/rehabilitation feelings in a non-
program for the threatening environment
individual. may help patient come to
terms with long-
Dependent: unresolved issues.

*Administer
stimulants drugs as * This measure is
prescribe by the important to maintain
doctor. gains and continue
progress if able.
*Give Antipsychotics
drugs such as
aripiprazole (Abilify)
to the patient as order
by the physician. *To help patient
struggling with
hyperactivity to gain
*Administer Serotonin better concentration
such as risperidone
(Risperdal), clozapine
(Clozaril), quetiapine *Patients with bipolar
(Seroquel), disorder who experience
ziprasidone (Geodon) mania or mixed episodes
and olanzapine may be treated with an
(Zyprexa) as prescribe atypical antipsychotic
by the doctor. drug.

*effective in treating the

symptoms of delusional
disorder.
LADYBELLE P. GOTOTOS PSYCH CODE: 157
BSN3-SET1 APPLICATION WEEK 9