ASSESSMENT

S: Wala ako maalala as verbalized by the patient. O:  Poor eye contact  Restlessness  Disorient to time and place

DIAGNOSIS
 Disturbed thought process related to mental disorder

PLANNING
 After of 1hr of nursing intervention the patient will able to maintain usual reality orientation

INTERVENTION
 Reorient to time, place, and person as needed.  Schedule structured activity and rest period  Listen with regard

RATIONALE
 Inability to maintain orientation is sign of deterioration  Provided stimulation without undue fatigue  To convey interest and worth to individual  Defensive reaction may result

EVALUATION
 After1hr of nursing intervention the patient will maintain usual reality orientation.

 Present reality concisely and briefly do not challenge illogical thinking  Reduce probative stimuli negative criticism argument and confrontation  Encourage client to eat. Provide pleasant environment and allow

 To avoid triggering fight/flight response

 Enhance intake and general well being

sufficient time to eat.  Assist in identifying ongoing treatment needs, rehabilitation program for individuals.

 To maintain gains and continue progress if able.

VERBAL
WORKING SATGE:

NON-VERBAL

ANALYSIS

N:magandang umaga po nay. P:magandang umaga din. N:kamusta po kayo? P:ok naman N:diba po nabanggit ninyo pos akin kahapon na sa sorsogon kayo nakatira P:Oo N: nay naalala nio pa po ba kung sino kasama ninyo sa sorsogon? P:wala di ko na alala. N:nasaan po mga magulang nio? P:di ko alam? N:e ung pong mga kapatid ninyo? P:di ko din alam. N:di ninyo po ba naalala kung ano pangalan nila ? P:di e. N:naalala nio po kung sino nag dala sainyo dito? P:di e. y Sad face. y She can t remember her fast memory y Look to other patient. y Smile again and she looks to other patient. y Smile at me.

N:di nio po sila natatandaan. P:matangkad na na babae maikli ung buhok mabait un. N:pano mo po nasabe na mabait siya? P:ewan. N: ahh sige po salamat po nay oras nap o para kumain tayo. y Look to other patient. (at this time it s already 12:10 patient need to eat their meals. )

VERBAL
TEMINATION STAGE: N: nay goodmorning po P: goodmorning din. N: nay nag enjoy po ba kayo kanina? P: oo naman nakakapagod lang. N: marunong po pala kayo sumayaw? P: oo ikaw nagturo ng sayaw diba? N: opo nay ako po. Sa tatlong araw po na natili kame dito ano ano po natutunan nio? P: madami. N: ano ano po un pwde po ba ninyo isa isahin? P: mag kulay kumata. N: ano pa po? y Smile. y

NON-VERBAL
Smile at me.

ANALYSIS

P: di ko na maalala e. N:nay bukas po huling araw na namin dito. P: ay ganun ba?wala na mag aalaga sakin ditto. N: meron naman po na papalit sakin dito na mag aalaga sayo. P: e baka di nila ako alagaan N: aalagaan ka po nila magaling din po sila mag alaga. P: ayoko! N: di po kase pwde na mag stay na lang kame dito madame pa po kame dapat alagaan. N:saan? P: saiba pa pong hospital. N: ay ganun. P: opo nay wagna po kayo malungkot.aalagaan naman po kayo nila e gaya ng pag aalaga naming senyo. Mamimiss nio po ba ako? N: oo dadalawin mo ba ako dito? P: pag po may libreng oras peropo di kop o pinapangako. y Sad face y She afraid to loss someone who will take care for her. Maybe she don t want happen again the time that she separated to her family. y Sad face

NAME

CLASSIFICATION
-therapeutic antihypertensives pharmacologic calcium channel blockers

ACTION
-Calciumchannel blocker

INDICATION -Treatment of essential hypertension and angina

CONTRAINDICATION ADVERSE
-Allergy to amlodipine -Hepatic or renal impairment -Sick sinus syndrome -Heart block -Sick sinus syndrome -Lactation EFFECT CNS: Dizziness Lightheadedness Fatigue Lethargy CV: Peripheral edema Arhythmias Dermatologic: Flushing, rash GI: Nausea Abdominal discomfort

NURSING RESPONSIBILITY
-Assess patient for history of allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block, or CHF. -Assess for adverse drug reactions; report irregular heartbeat, swelling of the hands and feet, shortness of breath, pronounced dizziness, and Constipation. -Monitor BP and cardiac Rhythm. -Instruct patient to take drug with meals if abdominal discomfort occurs; advise on eating small, frequent meals for Nausea and vomiting.

GENERIC NAME: amlodipine besylate BRAND NAME: Norvasc