PNO-Northern Negros State College of Science and Technology College of Nursing

CaseAnalysis of Patient with Bipolar Affective Disorder

Presented to: AmaliaBillote RN, RM, MN Andrea Marie Boherom RMT, RN, MN Presented by: Sabando, Christian M. Cabalatungan, XZ E. Camacho, Maricris Carpina, Bonnebelle J. Dela Pena, Kaname Diamante, KeansQuennie C. Dulana, Emariel Enero, Christine Anne G. Francisco, Sheila Mae A. Gauma, Leizel S. March 11, 2013

INTRODUCTION
People use the term mood to describe the emotional tones that color their daily lives. Moods are everywhere and ubiquitous; everyone has them. Moods may be happy or sad; energized or sluggish; embodying various combinations of emotional states. It consists of feelings as well as the thoughts and judgments that give feelings their meaning. An anxious mood may shift into an excited mood with a simple change of perspective, and a depressed mood may shift into a happier one upon hearing pleasing news. Moods are typically transient things that shift from moment to moment or day to day, but they can be prolonged states as well which color the whole psychic life for long periods of time. While people's moods rise and fall as various life events are experienced, most moods never become that extreme or feel uncontrollable. As depressed as an average person might get, it won't take too much for them to recover and start feeling better. Similarly, happy and excited moods are not easily sustainable either, and tend to regress back to a sort of average mood. Most people can't stay too depressed or too happy for any length of time. In contrast to people who experience normal mood fluctuations are people who have Bipolar Disorder. People with bipolar disorder experience extreme and abnormal mood swings that stick around for prolonged periods, cause severe psychological distress, and interfere with normal functioning.

Bipolar Disorder (also known as Manic Depression, or sometimes Bipolar Affective Disorder), is a category of serious mood disorder that causes people to swing between extreme, severe and typically sustained mood states which deeply affect their energy levels, attitudes, behavior and general ability to function. Bipolar mood swings can damage relationships, impair job or school performance, and even result in suicide. Family and friends as well as affected people often become frustrated and upset over the severity of bipolar mood swings. As of January 2012, statistics have shown that US has the largest number of bipolar cases reported all over the world in which about 2 million adults (roughly 1% of the adult population) suffer from some form of bipolar disorder. According to several studies, a significant proportion of the approximately 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of adolescent bipolar disorder, but have not yet experienced the manic phase of the illness. However, in the Philippines an extrapolated prevalence of 1,034,900 cases has been reported from last years population. The very reason we chose this case is to be more familiar with it. Aside from NLEs challenging questions centering on Bipolar Disorders, we would like to know the psychopathology and be able to appreciate this one of a kind mental disorder. From the word Bi our minds would like to find the answers to finally conclude how this type of mental disorder can be define into one.

OBJECTIVES
General Objective: Within 2 hours of case presentation, the group will be able to facilitate learning in the delivery of the case presentation about a client with Bipolar Affective Disorder to the class and the panel. Specific objectives:

KNOWLEDGE
1. Enumerate the predisposing factor that causes the patients Bipolar Affective Disorder. 2. Enumerate actual and potential problems related to patients mental disorder. 3. Explain the psychopathology of Bipolar Affective Disorder including the neurotransmitters involved. 4. Present nursing diagnoses and interventions for learning purposes of the whole class about the Bipolar Affective Disorder. 5. Explain the classification, indication, mechanism of action, route, and dosage of the medications given to the patient.

SKILLS
1. Present accurate and reliable datas regarding to patients Bipolar disorder for the achievements of desired goals. 2. Provide time to raise questions and clarifications for further understanding of the case presented. 3. Present individual tasks assigned to deliver an organized case presentation. 4. Note corrections and suggestions by the class and the panellist for improvement of the case presentation. 5. Provide materials needed for the case presentation. ( e.g. soft copy, hard copy, projector., Speaker)

ATTITUDE
1. Maintain confidentiality of the patients records throughout the case presentation. 2. Accept corrections and suggestions positively. 3. Prepare the room and needed requirements 15-30 minutes before the case presentation starts. 4. Show cooperation within the group during the case presentation. 5. Answer the questions honestly.

GENERAL DATA A. DEMOGRAPHIC DATA Name: R.A. Gender: Male Age: 53 years old Date of Birth: July 27, 1959 Place of Birth: Manila Address: 87 Chico St.,Brgy. Quirino ,2-B Quezon City, NCR Second District Marital Status: Single Nationality: Filipino Religion: Roman Catholic Fathers Name: R.A Mothers Name: A.A Educational Attainment: 2ndyear College Occupation: None Informant: R. A ADMISSION DATA Date of Admission: December 18, 2012 Type of Admission: Committed Time of Admission: 11:57 AM Ward: ACIS I- ward 9

Informants Complaints: Naglalayas , Nagwawala,Maingay, kung anolangangsinasabi Hindi nakasisiyanakainomnggamot Patients Complaint: Walanamanakongsakit Nilalasonninyoako, Bobo kayo, Mapapahiyalang kayo sa akin Admitting Diagnosis: Bipolar Affective Disorder current episode manic with psychotic symptoms Admitting Physician: Dr. A. C Vital signs upon admission: December 18, 2012 (11:57AM) Temperature: 37 C Blood Pressure: 130/90 mmHg Weight: (upon admission): 57 kgs. Height: 55 Vital signs during shift: February 8,2013 ( 10:00 AM) Temperature: 36.3 C Pulse Rate: 78 beats per minute Respiratory Rate: 18 cycles per minute Blood Pressure: 110/70 mmHg

PREVIOUS PSYCHIATRIC HISTORY

Patient was first diagnosed to have mental illness in 1998 and had his first admission at National Center for Mental Health. After couple of months he was advised that he can go home and was given Lithium to decrease the symptoms he manifested. It was back in 2010, he was admitted again for the second time due to his manic episodes triggered by the symptoms he manifested due to eliciting drugs again. Six months prior to admission, he was restless, irritable and had an aggressive behaviour after he left their home for four months without taking his medications anymore.

PRESENT PSYCHIATRIC HISTORY

Last December 18, 2012, Patient R.A was seen restless and was then so disturbing and violent that he had thrown unpleasant words to his neighbourhood and yelling to people whenever there are neighbours passed by the store nearby. He initiated a fight in which he was caught by the BaranggayOfficials and was then admitted by his younger brother to NCMH for the third time.

PHYSICAL ASSESSMENT
SKIN The patients skin is dark in complexion, has scars on both elbows and knees. It has no lesions and edema, whenpinched; the skin goes back to the previous state. The tissues surrounding the nails of the patient are intact. HEAD AND FACE The head is symmetrical and has no lesions noted. The hair is grayish-white, evenly distributed and is thin. The patient has symmetric facial movements. EYES PERRLA The patients eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement. Eyes have pink palpebral conjunctiva and anectericsclerae. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patients visual acuity is normal. EAR The patients external ear canal is dry, has no lesions and masses, and has no ear discharges, able to hear voices in different tones. NOSE The patient has no tenderness on sinuses. The nose is in the midline and has intact septum without nasal discharges. No signs of nasal deviation. MOUTH AND THROAT The patients buccal mucosa is uniformly pink in color, moist, smooth, soft, and has no lesions. Teeth are anteriorly incomplete and yellowish in color, gums are pink, moist, and firm, have no retraction and bleeding of gums. Tongue is pinkish in color. Uvula is positioned in the midline of soft palate. The tonsils are pink in color, and have no discharges.

NECK Neck is supple, non-distended neck veins noted, has non-palpable cervical lymph nodes, no injuries and inflammations. CHEST Normal in appearance, symmetrical and no chest retraction noted upon inhalation and exhalation. No abnormalities noted. RESPIRATION Respiratory rate: 18 cycles per minute, regular and even in rhythm. The depth is non-exaggerated with no respiratory effort noted upon inhalation and exhalation Symmetry: Thorax rises and falls bilaterally, no paradoxical movement. GASTROINTESTINAL Abdomen is soft, flat and non- tender No scars and marks noted No nodes or abnormalities noted EXTREMITIES Scars on both elbows noted Healed wounds at both anterior patellar region noted No gross deformities noted

MENTAL STATUS ASSESSMENT

GENERAL APPEARANCE Appears stated age (53yrs.old) Appears relaxed and has drooping posture Has grayish-white hair Well-groomed , dark complexion, and medium in built Sometimes manifests flat affect Hyperpigmented skin on right upper cheek Has moles on left earlobe area, Has scars on both elbows and knees Has coordinated body movements No gross deformity noted BEHAVIOR Oriented to time, date and place Maintains eye contact during interactions Crosses arms and legs, sometimes hands are place at the back of the head Cooperates well to the activities but easily gets bored

AMOUNT OR TYPE OF MOTOR ACTIVITY Occasional akathisia noted Demonstrating a shuffling like gait posture, mask-like facial appearance Has drooping posture Has no tremors, no hyperkinesias noted during the interview SPEECH PATTERN The patient is responsive Words are clear and intelligible Speaks in a fast and continuous manner, in a low tone of voice and monotonous intonation Vocabulary appropriate to socio-economic background Can speak English and Tagalog at the same time DEGREE OF CONCENTRATION AND ATTENTION SPAN Patient has a poor attention span. He can be easily distracted. Sometimes responds too slowly as part of processing of his thoughts ORIENTATION Patient is well oriented to time, place, person and date Able to identify student nurses names

 Patient is conscious and coherent Oriented to what kind of hospital he is confined right now. MEMORY Retrograde amnesia and sometimes with anterograde amnesia noted. Needs an ample time when identifying student nurses name Can sometimes recall historic people and events in the past He can answer simple mathematical problems when asked but needs time to answer. INTELLECTUAL FUNCTIONING He reached his 2nd year in college Has good formation of ideas Able to converse using Tagalog and English languages at the same time AFFECT Bit anxious when answering questions Sometimes he has flat affect Often, he displays feeling of sadness, hopelessness and helplessness MOOD Exhibits anxiety and sometimes displays withdrawal when the topic being discussed is about the reason why he was admitted at NCMH. Signs of depression noted

THOUGHT CLARITY He is conscious and coherent Manifesting circumstantiality of ideas THOUGHT CONTENT Patient has feelings of hopelessness and worthlessness. He had stated, Hindi konamanmasisimgakapatidko. Hirapnasilasa akin, pabigatnaako. Parangwalanaakongsilbidito. THOUGHT PROCESS REFLECTED IN SPEECH Appropriate response during interaction noted. Circumstantiality , tangentiality noted He has a passive suicidal ideation as he verbalized, Nahihirapannaako, ibaangmundonilasamundoko. Gusto kongmawalasamundo. INSIGHT Aware of his present condition and why he was admitted at NCMH but denies the fact that he is suffering from mental disorder. JUDGMENT Can formulate simple solutions to problems Has a good decision capacity He was able to distinguish shape, color and characteristics of a certain thing

MOTIVATION He really wanted to go home Patient participated well in the therapies being conducted He wished someone will visit him

CULTURAL AND SOCIAL HISTORY

Ethnicity/ Beliefs/Practices Patient is purely Filipino, was born and raised at Manila. His mother was native of Camarines Norte in Bicol region and his father from Manila. He is a Roman Catholic and believes that without God, life is so meaningless. He takes a bath three to four times in a week, and verbalized that he sleeps 5-6 hours in a day and is always fragmented due to increase urinary frequency. He voids more than 10 times in a day. He stated hes on a water therapy. Environmental Factors He was born at Manila. He grew and lived with his nephew at Quezon City in a crowded area. He had a poor relationship with his family members and his neighbors as well. He verbalized, Nungkabataanko, lahatng gusto ko ay binibigayngakingmgamagulang. Educational Background He reached his second year in college and he claimed that he is fond of people and events in the history. Substance Abuse The client claimed that he started to ilicit drug, smokes and take alcohol during his college years (2nd yr) due to peer pressure which contributes to his present condition. He can consume 1-2 sticks per day.

PSYCHODYNAMICS

Freuds Theory of Psychosexual

Psychosexual Stage Behaviors Reflecting Mastery Child explores the world by using mouth, typically through feeding and sucking Interested in oral stimulation or pleasure during this time Toddler (anal stage) 18 months 3 years old Child learns to control urination and defecation Superego develops Self discovery Achieved Not Achieved BehaviorsReflecting Psychosexual Problem -Fear of criticism -Dissatisfaction and hostility -Withdrawal from others -Infantile behavior -Denial of problems

Infant (oral stage) 0 -18 months

-Dependence on parents and others, for approval -Sense of being out of control of self and ones life -Feeling of being exposed or attacked

Psychosexual Stage

Behaviors Reflecting Mastery

Achieved

Not Achieved

BehaviorsReflecting Psychosexual Problem rumination and self-pity excessive guilt/embarrassment

Preschooler (phallic stage) 3 6 years old

Child learns sexual identity through awareness of genital area curiosity and exploration childs personality development appears to be nonactive or dormant Sexual desire diminishes and attention turns to development of talents and skills Play with same sex peers and avoid opposite sex peers. ability to care about and relate to others outside home

School age (latent stage) 6-12 years old

overly high achieving feeling unable to gain love or affection

unless totally successful Feeling unworthy and inadequate Lack of friends of the same sex

Psychosexual Stage

Behaviors Reflecting Mastery

Achieved

Not Achieved

BehaviorsReflecting Psychosexual Problem projection of blame and ones feelings Persistent aloneness or isolation Emotional distance in all relationships Prejudices against others Withdrawal and loneliness

Adolescent (genital stage) 12 years old and up

Adolescent develops sexual maturity and learns to establish satisfactory relationships with the opposite sex. Sexually desires remerge planning life goals

ERIK ERIKSONS PSYCHOSOCIAL THEORY

Life Stage

Adult Behavior Reflecting Mastery

Achieved

Not Achieved

Adult Behaviors Reflecting Developmental Problems (as manifested by client)

- Fear of criticism and closeness - Dissatisfaction and hostility - Denial of problems - Withdrawal from others

- Realistic trust of self and others I.Trustvs Mistrust (0-18 months) - Confidence in others - Optimism and hope - Sharing openly with others

- Self-control and willpower II. Autonomy vs. Shame and Doubt - Realistic self-concept and self-esteem - Pride and a sense of good will cooperativeness - Simple

-Sense of being out of control of self and ones self -Excessive independence or defiance -Impulsiveness or inability to wait

- Knowing when to give and take - Delayed gratification when necessary

Life Stage

Adult Behavior Reflecting Mastery

Achieved

Not Achieved

Adult Behaviors Reflecting Developmental Problems (as manifested by client)

- passitivity and apathy - Reluctance to show emotions

-An adequate conscience III. Initiative vs. guilt (3-5 years) -Initiative balance with restraint -Appropriate social behaviors -Curiosity and exploration -Healthy competitiveness -Original and purposeful activities

IV. Industry vs Inferiority (6-12 years)

-sense of competence - completion of projects -Pleasure in effort and effectiveness - ability to cooperate and compromise - Identification with others - sense of direction - balance of work and play

-Lack of friends of the same sex

Life Stage

Adult Behavior Reflecting Mastery

Achieved

Not Achieved

Adult Behaviors Reflecting Developmental Problems (as manifested by client)

Persistent aloneness or isolation

V. Identity vs. role diffusion

- Confident sense of self - Commitment to peer group values - Emotional stability - Development of personal values - Emotional stability - Development of personal values -Sense of having a place in society - Establishing relationship with opposite sex - Testing out adult roles

-Emotional distance of relationships

VI. Intimacy vs. isolation (18-25 or 30 years old)

-Ability to give and receive love -Commitments and mutuality with others -Collaboration in work and affiliations -Sacrificing for others -Responsible sexual behaviors -Commitment to career and long term goals -lack of interest in the welfare of others -

RESPONSES OF THE CLIENT TO DIFFERENT THERAPEUTIC ACTIVITIES

A. .Music and Art Therapy He was oriented during the activity and showed a little bit interest to it. He got instructions clearly and verbalized Ito ang pagdrawing gamit ang dalawang music, ano nga ba iyon? Soft at hard? which gave us the idea that he was already familiar with the therapy that has been conducted. When soft music was played, he wrote his name correctly. He drew a mango tree. He explained that the mango tree symbolizes peacefulness/ tahimik for him. For the fast music, he drew the sun, the mountains and the green fields. He stated, Naglalarawan ito ng kasiyahan, masaya yet obviously opposite to the facial expression he projected. B. Remotivation Therapy This was the first activity conducted. Remotivation therapy was facilitated, patient R.A. enjoyed the discussion and participated well during the activity. Patient was listening well when the instructions were given out. As the question raised centering on fruits and its nutritional content, patient shared one of his favorite fruit Longgan. This kind of fruit is only known to people who can afford to buy it. After the therapy, he verbalized Salamat, nakatikim rin ako ulit ng mga ito, which satisfied his need for food. C. Occupational Therapy Following the systematic method in creating the product which is box-making, in this therapy, patient successfully made a cute gift box. He really paid attention to the steps given by the facilitator. Patient verbalized, Ibibigay ko ito kung my dadalaw. He put his efforts just to make himself a wonderful gift box he designed by his own. D. Play Therapy Patient R.A is so cooperative that he was able to participate from all the games facilitated then. He could easily get the instructions but sometimes gets easily bored when too much time was spent for such activity.

E. Community Singing/Action Song Patient was able to follow instructions well and was very cooperative. He has an idea on how to sing and act out the action songs, Leron leron Sinta and Fruit Salad so he was able to sing and act out well. He was able to follow in Alive, Alert, Enthusiastic and Ang Buhay ng Pinoy. In the song, Kanlungan at Hawak Kamay, he also sang well and able to join the group while having a bit of fun singing and enjoying together with the other patients. F. Bibliotherapy Patient listened well to the told story. He responded well to every questions raised. He shared his views about the moral lessons he got from the story. His statements were Kailangan may pagtutulungan at pagkakaisa. Di dapat tatamad-tamad para may magawa ka. G. Newspaper Reading Patient R.A. was oriented to time and was able to answer the purpose of newspaper reading. He followed the facilitator upon reading the newspaper. He got information on Halo-Halo tips clearly. He stated, Ang mga nakuha kong punto ay makakatulong tulad ng mga pangunahing lunas na magagamit sa araw-araw. H. Dance/Exercise Therapy At first, patient R.A was not that too lively to participate in dance therapy and in performing daily exercises. Later as what we have observed, he could already follow the steps and gestures well, coupled with some facial expressions.

LABORATORY STUDIES Hematology

Hemoglobin

Normal Values
140-180g/L

Result
110g/L

Indication
Below normal; Anemia

Nursing Consideration
<Encourage Patient to eat foods rich in iron like green leafy vegetables; camote leaves and malunggay. >Encourage Patient to increase oral fluid intake >Emphasize to the patient the importance of compliance in medication

Hematocrit RBC Count

0.40-0.54 4-6x1012g/L

0.35 3.65g/L

Below Normal; Anemia Below Normal; Anemia

WBC Count Differential Count Neutrophil Lymphocyte Monocyte Eosinophil Stab Basophil

5-10x109g/L

7.2

Normal

0.45-0.65 0.20-0.35 0.02-0.06 0.02-0.05 0.02-0.04 0.00-0.005

0.60 0.31 0.05 0.04 -

Normal Normal Normal Normal

Clinical Chemistry Electrolytes Determination:

Sodium Potassium Lithium

Result

Normal Values

Indication

Nursing Intervention

1.29

135-150mmol/L 3.4-5.5mmol/L Below 0.2mmol/L Therapuetic Range (0.5-1.4mmol/L) >Monitor for Lithium level for it has very narrow margin of safety >Maintain usual lithium dose its dangerous in over dosage >increase oral fluids

Blood Chemical Exam

Result

Normal Values

Indication

Nursing Consideration

BUN

2.47umol/L

2.70-7.10umol/L

Normal

Instruct patient to avoid eating foods rich in sodium especially canned foods. Instruct patient to avoid foods like pork and animal meats.

Creatinine

81.90umol/L

62-115umol/L

Normal

Urine Analysis Date: December 20,2012 Residence Physician: Dr. Valdez Gross Examination Color: Light yellow Transparency: Slightly turbid Specific Gravity: 1.015 pH: Acidic Protein: Negative Sugar: Negative Indication: Normal Nursing Consideration: Encourage patient to increase oral fluid intake Encourage to eat food rich in Vitamin C like vegetables and fruits, such as pineapple, orange, guava and mangoes. Microscopic Findings WBC: 1-2/hpf RBC: 0-2/hpf Epithelial cells: few Mucus Threads: moderate Amorphous Urates: moderate

PROBLEM LISTING
CUES: SUBJECTIVE: Patient verbalized, Nakakalungkot dito, gusto kong makawala. Kasalanan ko naman eh, tumikim ako ng droga na alam ko mali iyon. Hindi ko na nagagawa ang mga ginagawa ko noon. Na mimiss ko na talaga ang pagkanta. Nahihirapan na ako, iba ang mundo nila sa mundo ko. Hindi na ako nadalaw simula noong January 5 pa. Hindi ko naman masisi mga kapatid ko. Hirap na sila sa akin, pabigat na ako. Gusto kong mawala sa mundo.Parang wala na akong silbi dito. Paputol-putol yung tulog ko. Dahil sa ingay nila, yun nagigising ako at nahihirapan na matulog ulit. Hindi ako komportable, malamig pag-gabi.

Distractibility OBJECTIVE: Poor attention span Occasional akathisia Rapid speech with low tone of voice Withdrawal Daytime sleepiness Saddened facial expression Lack of energy Drooped posture Low self-esteem Vital signs:February 8,2013 Temperature: 36.3 C Pulse Rate: 78 beats per minute Respiratory Rate: 18 cycles per minute Blood Pressure: 110/70 mmHg

Laboratory results:

BLOOD CHEMICAL EXAM Hemoglobin-110g/L Hematocrit-0.35

RBC Count-3.65g/L WBC Count:7.2g/L

Learning Facilitation
The term mental health encompasses a great deal about single person including his behavior, how he feels, and how he functionas an individual. This single aspect of a person cannot be measured or easily reported but it is possible to obtain a global picture by collecting subjective and objective information to delve into a persons true mental health and well being. Psychiatric student nurses are pivotal in the enactment of therapeutic communication and care to patient with mental disorders. This Bipolar case we opt to select is not merely new to us though we have few backgrounds of the said disorder but then its a bit challenging in our part to choose this for our case study due to constricted time allotted and we must go beyond depth discussion and learning for this case. Each one in our group had imparted their knowledge just to make this a success one. Prior to making this study we go through a numerous critique and analysis and distinguish what are applicable data to be incorporated. We also had appreciate what are the actual manifestations of these type of clients. Taking care of these personsis unique in all fields of nursing. Being a psychiatric nurse does not only require you to be a multi-tasker , above all, it requires you to adapt and understand their behavior because this client are manifesting an unexplainable actions that deviates from the normal behavior of a normal person. This exposure helped us learn the deeper meaning of nursing, the art that the other profession cannot see. We can say that our skills are almost complete because of these. The trials maybe tough but the prize is very worth it, the hardships and the sacrifices are nothing as long as you know that you have contributed something that could possibly enhance their being as a person, in behalf of the group members, we would like to extend our gratitude to the almighty God for the strength, to our classmates who supported us, to our group mates who shared the endeavor, to the clinical instructors whos love and understanding are endless and to our parents, we are now starting to see the fruit of our toil. The battle against the board exam is about to come, and with this knowledge, we know we can make it.

PROBLEM LISTING

BEHAVIORAL PROBLEM RANK ACTUAL

Ineffective coping related to inadequate social support created by characteristics of relationships

POTENTIAL

Depression

Risk for self directed violence related to mental disorder and depression

Passive Suicidal Ideation 2

Hopelessness related to feelings of inadequate social support

Risk for suicide related to feelings of worthlessness

NCP FOR DEPRESSION

Patient Name: R.A. Age/Sex: 53 years old, Male Ward: Ward 9, Pavilion1 Attending Physician: Dra.A.C. General Objective: To identify and accept positive and negative expressions, feelings and reactions. SUBJECTIVE CUES: Patient verbalized, Nakakalungkot dito, gusto kong makawala. Kasalanan ko naman eh, tumikim ako ng droga na alam ko mali iyon. Hindi ko na nagagawa ang mga ginagawa ko noon. OBJECTIVE CUES: Poor attention span Rapid speech with low tone of voice Withdrawal Saddened facial expression Distractibility Lack of energy
Laboratory results:

Reason for Admission: Nagwawala, Naglalayas Admitting Diagnosis: Bipolar Affective Disorder, Current Episode, Manic with Psychotic Symptoms

Blood Pressure: 110/70 mmHg

BLOOD CHEMICAL EXAM Hemoglobin-110g/L Hematocrit-0.35 RBC Count-3.65g/L WBC Count:7.2g/L

Drooped posture Low self-esteem Vital signs:February 8,2013 Temperature: 36.3 C Pulse Rate: 78 beats per minute Respiratory Rate: 18 cycles per minute

Nursing Diagnosis

Expected Outcome

Nursing Intervention

Rationale

Evaluation

Ineffective coping related to inadequate social support created by characteristics of relationships

Within 42 hours of nursing intervention, patient will be able to: 1.Develop trust towards medical professionals.

INDEPENDENT 1. Establish trusting relationship with client by attending his needs, assisting in him in every activities, friendly approach, listening well and giving information correctly. >The therapeutic nurse-client relationship is built on trust.

After 42 hours of nursing intervention, goals were partially met as evidenced by: 1. Clients developed trust to the nurse by sharing his experiences from the past

2.Verbalize feelings, fears and anxieties. 2. Identify developmental level of functioning by gathering information 3.Identify ineffective coping about patients history. behaviours and consequences. 3. Determine individual stressors (e.g. 4. Demonstrate use of more family, social, work, environment, life adaptive coping skills as changes, etc.) evidenced by interactions and willingness to participate in 4. Call client by name. Ascertain how the therapeutic community. client prefers to be addressed. 5. Engage in a meaningful communication.

>People tend to regress to a lower developmental stage during illness or crisis.

5. Determine alcohol intake, drug use, smoking habits, sleeping, and eating patterns. 6. Note speech and communication patterns. Be aware of negative or catastrophizing thinking.

>To determine degree of impairment as well as formulate appropriate plan of care for client 3. Clients identification of various stressors in his life. >Using clients name enhances sense of self and promotes individuality and self-esteem. 4. Clients appropriately interacts and cooperates >These mechanism are often with staff and participated used when individual is not actively on the activities coping effectively with stressors. and therapies. 5. Clients responded >People under crisis often have appropriately during problems with communication conversation. thereby inhibiting them from developing meaningful interpersonal relationship.

2.Clients freely verbalization of feelings, fears and anxieties towards the nurse

7. Use reality orientation and make frequent references to time, place, as indicated. 8. Explain procedures and events in a simple and concise manner. Devote time for listening. 9. Provide a quite environment and position equipment out of view as much as possible.

> To assist client to deal with current situation.

>May help client to express emotions, grasp situation and feel more in control. >When anxiety is increased by noisy surroundings or site of medical equipment.

10. Treat client with courtesy and respect by talking on a soft slow manner. Converse client level, include greetings and provide meaningful conversation while performing care. DEPENDENT 1. Administer antipsychotic and antidepressants as prescribed: Haloperidol (haldol) 20 mg BID (8am, 6pm) Lithium carbonate 450mg 1tab BID 2.Monitor laboratory values. COLLABORATIVE: 1.Collaborate with other health care provider in monitoring patient for alterations in physical (vital signs) or cognitive function.

>Enhances therapeutic relationships.

-Short-term management of behavioral disturbances.

-To identify abnormalities. -Aids in providing appropriate care.

NCP FORPASSIVE SUICIDAL IDEATION

Patient Name: R.A. Age/Sex: 53 years old, Male Ward: Ward 9, Pavilion1 Attending Physician: Dra.A.C. General Objective: To identify and accept positive and negative expressions, feelings and reactions. SUBJECTIVE CUES: Nahihirapan na ako, iba ang mundo nila sa mundo ko. .Hindi na ako nadalaw simula noong January 5 pa. OBJECTIVE CUES: Poor attention span Rapid speech with low tone of voice Withdrawal Saddened facial expression Gusto ko ng mawala sa mundo. Parang wala na akong silbi dito. Reason for Admission: Nagwawala, Naglalayas Admitting Diagnosis: Bipolar Affective Disorder, Current Episode, Manic with Psychotic Symptoms

Hindi ko naman masisi mga kapatid ko. Hirap na sila sa akin, pabigat na ako.

Distractibility Lack of energy Drooped posture Low self-esteem

Vital signs:February 8,2013 Temperature: 36.3 C Pulse Rate: 78 beats per minute Respiratory Rate: 18 cycles per minute Blood Pressure: 110/70 mmHg RBC Count-3.65g/L WBC Count:7.2 g/L

Laboratory results: BLOOD CHEMICAL EXAM

Hemoglobin-110g/L Hematocrit-0.35

Nursing Diagnosis

Expected Outcomes Within 42hours of nursing intervention the patient will be able to: 1.recognize and verbalize feelings 2.be safe and free from injury 3.participate actively in diversional activities 4.develop positive attitude and outlook 5.refrain from gathering means of suicide 6.show interest in the surrounding 7.absence of suicide ideation 8.Seeks help when feeling self-destructive

Nursing Intervention INDEPENDENT 1.Determine history of suicide attempts 2.Determine whether patient has specific suicide plan identified by asking patient when,where and how his plans of suicide 3. Assess coping mechanism anddefense mechanism displayed by the patient . 4.Refraining from negatively criticizing and avoid statements such as do nots 5.Encourage client to verbalize and explore feelings 6.Establish a therapeutic and facilitative relationship with the patient. 7.Maintain a pleasant, quiet environment and approach client in a slow, calm manner. 8.Listen with regard.

Rationale

Evaluation After 42 hours of nursing interventions, goals were partially met as evidence by patient was able to: >recognized and verbalized feelings of sadness and happiness

Hopelessness related to feelings of inadequate social support

>To assess causable factors >To promote safety

>To assess contributing factors >To promote positive attitude and enhance well-being >Enhances trust and therapeutic relationship >Client may feel safe to disclose feelings and feel understood and listened to. >Client may respond with anxious or aggressive behaviors if startled or overstimulated. >To convey interest and worth to individual. >Client may feel threatened and may withdraw or rebel.

> safe and free from injury >participated actively in diversional activities like therapies >developed positive attitude and outlook as verbalization of magpaplanonangmgagag awinsapaglabastuladngpag kainngmasasarapnapagkai n >refrained from gathering means of suicide >showed interest in the surrounding especially during group activities

9.Refrain from forcing activities and communication.

10.Prevent situation that might lead loneliness and isolation.

>Isolation and loneliness may aggravate suicidal ideation >Provides stimulation while reducing fatigue. >To promote wellness

11.Schedule structured activity and rest periods. 12.Demonstrate and encourage use of relaxation exercises, guided imagery 13.Express hope to client and encourage to participate in every activities

(community singing, exercises and dance therapy) >no any verbalization about suicide

14.Protect patient from harming self and remove dangerous items from the environment(e.g., sharp items, belts, ties, straps, breakable items) 15.Provide positive feedback for actions by giving recognition. DEPENDENT 1.Administer medication as indicated: haldol (Haloperidol) 20 mg BID (8am, 6pm) Lithium carbonate 450mg 1tab BID 2.Monitor laboratory values.

>Promoting dealing with situation in manageable steps, enhances chances for success and sense of control >To promote safety

>To encourage continuation of desired behaviors.

Short-term management of behavioral disturbances.

-To identify abnormalities.

COLLABORATIVE: 1.Collaborate with other health care provider in monitoring patient for alterations in physical or cognitive function 2. Monitor vital signs -physical and cognitive function might lead to unsafe behaviour

-Aids in providing appropriate care

DRUG STUDY
GENERIC/ BRAND NAME, ROUTE, DOSSAGE biperiden HCl 2/3tab PO OD

CLASSIFICATION

INDICATION

MECHANISM OF ACTION

ADVERSE REACTION

NURSING CONSIDERATION

Antiparkinsonism

Adjust the therapy of parkinsonism Relief the symptom of EP disorder

Help normalize the hypothesized imbalance of cholinergic and dopaminergic nuerotransmitter in the basal ganglia in the brain of a parkinsonism patient

CNS: Disorganization, confusion, memory loss, hallucination

Give with meals if GI upset occur; give before meals if patient with dry mouth; give after meals if drooling or nausea occur. Ensure that the patient voids just before receiving each dose of drug if urinary retention is the problem Decrease dosage or d/c temporarily if dry mouth makes swallowing or speaking difficult. Instruct patient to report if difficult or painful urination, rapid or pounding heartbeat, confusion, eye pain or rash occur.

GENERIC/ BRAND NAME, ROUTE, DOSSAGE lithium carbonate 450mg 1tab BID

CLASSIFICATION

INDICATION

MECHANISM OF ACTION

ADVERSE REACTION

NURSING CONSIDERATION

Antimanic drug

Treatment of manic episodes of bipolar disorder, maintenance therapy to prevent or diminish frequency and intensity of subsequent manic episodes

Decreases intraneuronal content of second messengers and may thereby selectively modulate the responsiveness of hyperactive neurons that might contribute to the manic stage.

CNS: Slurred speech, muscle weakness, lethargy. GI: nausea and vomiting, diarrhea, thirst.

Monitor clinical status closely, esp. during initial stages of therapy. Decrease dosage after the acute manic episode is controlled. Ensure that patient maintains adequate intake of salt and fluid. Instruct patient to report if stomach or flank pain, unusual tiredness, confusion, difficulty breathing occur.

haloperidol 20g PO BID

Antipsychotic

Management of manifestation of psychotic disorder

Blocks post psynaptic dopamine receptor in the brain, depress the RAS

GI:Nasal congestion, nausea and vomiting, anorexia, dry mouth GU: urinary retention, CNS:drowsiness

Gradually withdraw drug when patient has been on maintenance therapy to avoid withdrawal-emergent dyskinesias Discontinue drug if serum creatinine or BUN become abnormal or if WBC count decreased Maintain fluid intake and use precaution against heatstroke in hot weather.

GENERIC/BRAND NAME, ROUTE, DOSSAGE diphenhydramine HCl 50g/cap

CLASSIFICATION

INDICATION

MECHANISM OF ACTION Competitively blocks the effects of histamine at H1 receptor site, atropine-like, antipruritic and sedative effects.

ADVERSE REACTION CNS: drossiness, sedation, dizziness, confusion, restlessness, headache. GI: increase appetite and weight gain, nausea, vomiting and constipation.

NURSING CONSIDERATION

Antiparkinsonism

Parkinsonism(including drug induced parkinsonism and EP reaction)

Monitor patient response and arrange for adjustment of dosage to lowest possible effective dose. Take with food if GI upset occurs. Instruct patient/SO to report if difficulty breathing, hallucination, tremor, visual disturbances occur. Monitor temperature if fever occur, rule out underlying infection and consult physician for appropriate comfort measure. Monitor patient regularly for signs and symptoms of DM. Instruct patient/SO to report if lethargy, weakness, fever, sore throat, malaise, palpitations occur.

risperidone quicklet 2mg/tab 1tab SL

Antipsychotic

Short term treatment of acute manic or mixed episodes associated with bipolar I disorder

Blocks dopamine and serotonin receptors in the brain, depresses the RAS.

CNS: insomnia, anxiety, agitation, headache, aggression. GI: nausea, vomiting, constipation, dry mouth, increase saliva.

Plan
HYGIENE Oral care Nail care Daily bath Clean clothing

Problem
Recurrence of DEPRESSION

Health Teaching PROMOTIVE 1.Encourage the patient to express his feelings and make time to listen to concerns.

Rationale

>To help client sort out thinking and begin to develop understanding of situation and look at other alternatives. >To lessen sense of anxiety and associated physical manifestation s. >To promote wellness.

ACTIVITY Exercise DIET Diet as tolerated INSTRUCTIONS Strict compliance of medications. Follow up check up after week of discharge.

2.Encourage the client to identify more appropriate solutions/ behaviours. 3.Encourage the significant others to provide comfort to the client and availability as well as caring for physical needs. 4.Encourage the client to participate in recreational or special interest activities in setting that client views as safe. 5.Encourage the client to take a bath everyday and teach him the importance of proper hygiene. PREVENTIVE
1.Encourage family to provide a quiet ,calm,

>To alleviate conditions contributing to clients sense of isolation. > Proper hygiene promotes sense of well-being.

atmosphere. 2.Instruct the family members to set limits on acting out behaviours of the client and learn ways to express emotions in an acceptable manner. 3.Encourage restful environment where possible .

>Helps client to think about self in the context of current situation. >It enables the client to maintain self concept and feel more positive about self.

>Listening and a quiet demeanor can convey acceptance o the client.

4.Advise the family or S.O. to help the client in setting limits on acting out behaviours and learn way to express emotions in an acceptable manner. 5.Encourage structured or controlled increase in physical activity. 6.Encourage client to avoid strenuous activity. CURATIVE 1.Encourage ongoing family /individual therapy as long as it is promoting growth and positive change. 2.Instruct the family or S.O. for occasional follow-up as appropriate. 3.Encourage family members to provide emotional support. REHABILITATIVE 1.Instruct the client to return to the hospital for follow-up check up. 2.Compliance of medication

>It promotes internal focus of control.

>Enhances sense of well being.

>To prevent fatigue.

>To promote wellness.

>For reinforcement of positive behaviours after professional relationship has ended. >To promote wellness of client.

>To assess progress and recovery of clients health condition.