INTRODUCTION Psychosis is characterized by a loss of connectedness with reality.

A person may develop false ideas or beliefs about reality (delusions) which in themselves may be based on false perceptions (hallucinations). People experiencing psychosis also have characteristic flaws in the ways they think. These are termed thought disorders. Examples are tangential thinking, loose associations between ideas, and incoherence. Psychosis significantly impairs work, family and social functioning. People with psychoses often experience poorer physical health. The worse the psychotic symptoms are, the higher the associated level of impairment. . Psychotic symptoms can occur in response to physical conditions, e.g. acute

delirium with septicemia. Alternatively, psychoses can be functional. There are two broad classes of functional psychotic disorders: schizophrenia and bipolar disorder. Generally, schizophrenia is a chronic condition with exacerbations, but always with some background symptoms. Bipolar disorder is generally an intermittent condition with the expectation of full recovery between episodes. There is considerable overlap between the two conditions and fluidity of diagnosis. Symptoms of schizophrenia are sometimes grouped into two categories: Positive symptoms such as hallucinations and delusions. Negative symptoms such as social withdrawal and lack of energy and motivation

that are similar to those found in depression. While the clinician may realize that the psychosis could be drug-induced and is cautious in the prescription of narcoleptics or sedatives to control the symptoms, they may be under pressure to respond to the manifestation of bizarre or potentially destructive
1

thinking or behavior. On the other hand, alterations to the way the person behaves and thinks may be subtle in the early stages when early intervention may be most appropriate. Shortening the period of untreated psychosis (whether this be substance induced or the early stages of psychotic disorders) has the potential to have a positive impact on treatment outcomes. (http://www.nationaldrugstrategy.gov.au) Schizophrenia is a disorder in which patients have psychotic symptoms and social and/or occupational dysfunction that persists for at least 6 months. Schizophrenia affects I % of the population. The typical age of onset is the early 20s for men and the late 20s for women. Women are more likely to have a first break later in life; in fact, about one third of women have an onset of illness after age 30. Schizophrenia is diagnosed disproportionately among the lower socioeconomic classes; although theories exist for this finding, none have been substantiated. The etiology of schizophrenia is unknown. There is a clear inheritable component, but familial incidence is sporadic and schizophrenia does occur in families with no history of the disease. Schizophrenia is widely believed to have a neurobiological basis. The most notable theory is the dopamine hypothesis, which posits that schizophrenia is due to hyperactivity in brain dopaminergic pathways. This theory is consistent with the efficacy of antipsychotics (which block dopamine receptors) and the ability of drugs (such as cocaine or amphetamines) that stimulate dopaminergic activity to induce psychosis. Postmortem studies also have shown higher numbers of dopamine receptors in specific subcortical nuclei of schizophrenics than in normal brains. More recent studies have focused on structural and functional abnormalities through brain imaging of schizophrenics and control populations. (http://www.health.am)

Schizophrenia is a disorder characterized by what have been termed positive and negative symptoms, a pattern of social and occupational deterioration, and persistence of the illness for at least 6 months. Positive symptoms are characterized by the presence of unusual thoughts, perceptions, and behaviors (e.g., hallucinations, delusions, agitation); negative symptoms are characterized by the absence of normal social and mental functions (e.g., lack of motivation, isolation, anergia, and poor selfcare). The positive versus negative distinction was made in a nosologic attempt to identify subtypes of schizophrenia and because some medications seem to be more effective in treating negative symptoms. Clinically, patients often exhibit both positive and negative symptoms at the same time. Table 1-2 lists common positive and negative symptoms. To make the diagnosis, two (or more) of the following criteria must be met: hallucinations, delusions, disorganized speech, grossly disorganized or catatonic (mute and/or posturing) behavior, or negative symptoms. There must also be social and/or occupational dysfunction. The patient must be ill for at least 6 months. Patients with schizophrenia generally have a history of abnormal premorbid functioning. The prodrome of schizophrenia includes poor social skills, social withdrawal, and unusual (although not frankly delusional) thinking. Inquiring about the premorbid history may help to distinguish schizophrenia from a psychotic illness secondary to mania or drug ingestion. (http://www.health.am/psy/more/schizophrenia/#ixzz2SCam9t8v)

Objectives To know the underlying cause of the disorder of my client. To understand the causative factors leading to this condition by gathering information from the clients history. To know its desired medication by making a drug study for it. To provide proper nursing intervention. To provide the appropriate care to my patient.

Scope and limitation The study focuses on the admitting diagnosis of patient C having a Chronic Psychosis. She was admitted at St. Dymphna Foundation Drop- in Center, Agay-ayan Gingoog City. The study covers the patients health history, present illness , laboratory exams and result, psychiatric diagnosis, medical diagnosis, and medical & nursing management. The study is also limited from the information being collected from the patient and his personal chart. The data gathering was also limited during the confinement of the patient. The study is limited to Chronic Psychosis.

Patient profile

Name: Patient C Age: 57 y.o Sex: female Date of birth: June 4, 1955 Add: Brgy 16 Gingoog city Religion: Roman Catholic Educational Attainment: Elementary Graduate Primary Care Provider: Saint Dymphna Drop in center foundation Date admitted: February 15, 2006 Medical Diagnosis: Chronic Psychosis Attending Physician: Dr. Lagat Accompanied by: Chief complain: Talks but doesnt make sense

Developmental Data

Erik Eriksons Theory: Generativity vs Stagnation (25 to 65 yrs. Old) At this stage the person is Creative, Productive and concern for others, they only think the situation of other people than for their own good. Observation: I observed that my patient always thinks about her children and her brother and sister even if she is in St. Dymphna. She misses her family a lot she states that Gusto nko mu uli sa amo maam para makita nako akong mga anak og igsoon. She is productive and creative and she always participates in all the activities that we gave them or ask them to do.

Harry Stack Sullivans Theory: Interpersonal Theories This theory emphasized the importance of interpersonal relations. He insisted that personality is shaped almost entirely by the relationships we have with other people. Sullivans principal contribution to personality theory was his conception of developmental stages. At this stage the patient need for special sharing relationship shifts to the opposite sex, and if the self-esteem is intact, areas of concern expand to include values, ideals, career decisions, and social concerns.

Observation: With my patient, she is close to her sister and brother. She often talks a lot of her older sister and how her sister helped her during the time of her illness. I also observed that my patient showed changes in her mood every day, sometimes she shows happy emotions but sometimes she just kept silent as an indication that she was not happy and was not in the mood but even though she just kept silent she participates in the activity.

Robert Havighursts Theory: (Middle Age) He believed that learning is basic to life that people continue to learn throughout life. He describe growth and development as occurring during six stages, each associated with six to ten task to be learned. At this stage the client will establishing and maintaining an economic standard of living, relating oneself to on es spouse as a person, Accepting and adjusting to the physiologic changes of middle age. Observation: I observed with my patient that she wants to explore something in her life and that even though she is alone but she tried to relate herself with other people and with her co residents as her family. Every time we gave her an activity to perform she does well on it and she was able to answer my questions most of the time.

Assessment

PSYCHIATRIC HISTORY AND ASSESSMENT TOOL

Identifying/Demographic Information Name: Carmencita Salucana Primary Care Provider: Saint Dymphna Drop in Center DOB: June 4, 1955 Age: 57 Race: Filipino Marital Status: Married Highest Educational Level: Elementary Graduate Religious Affiliation: none City of Residence: Gingoog Name/Phone # of Significant Other: NONE Primary Dialect/Language Spoken: bisayan Accompanied by: Admitted from: house Previous Psychiatric Hospitalizations (#): none Chief Complaints: Talks but doesnt make sense DSM-IV TR Diagnosis (previous/current) : substance abuse:amphetamine with cooccurrence of psychiatric psychosis Family Members/Significant Others Living in Home NAME RELATIONSHIP AGE OCCUPATION/GRADE Luis Pacudan Husband Samson Son Roel David Son Room No. Female ward Sex: Male Ethnicity: filipino No. Marriages: 1 Female

Past Psychiatric Treatments / Medications It is important to obtain a history of any previous psychiatric hospitalizations, the number of hospitalizations and dates, and to record all current/past psychotropic medications, as well as other medications the client may be taking. Ask the client what has worked in the past, and also what has not worked, for both treatments and medications. Current Psychotropic Medications/ Other Medications Name Dose/Dosages Treatment Length Response Comments

fluphenazine chlorpromazine

0.5 cc IM Deep 100 mg 1 tab

8

MENTAL STATUS ASSESSMENT AND TOOL

Presenting Problem: Resident was addicted to prohibited drugs amphetamine and shows signs and symptoms of psychosis. Her sister admitted her because he walks and rooms around the city with no food and dirty outfit.

(Describe)

Grooming/dress Hygiene Eye contact

Posture Identifying features (marks/scars/tattoos) Appearance versus stated age Congruent Congruent Congruent Congruent congruent Overall appearance Good Good Good Good Good NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help the client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion with: Tell me more. A less direct and more conversational tone at the beginning of the interview may help reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship.

APPEARANCE Day 1 Day 2 Well Well groomed groomed Neat & Neat & Clean Clean Direct eye Direct eye contact contact Stoop Stoop With scars With scars

Day 3 Well groomed Neat & Clean Direct eye contact Good With scars

Day 4 Well groomed Neat & Clean Direct eye contact Good With scars

Day 5 Well groomed Neat & Clean Direct eye contact Good With scars

(Check if present)

BEHAVIOR/ACTIVITY Day 1 Day 2

Day 3

Day 4

Day 5

Hyperactive Agitated Psychomotor retardation Calm Tremors Unusual movements/gestures Catatonia Akathisia Rigidity Facial movements (jaw/lip smacking) Other specify:

(Describe)

Slow/Rapid Pressured Tone Volume (loud/soft) Fluency (mute/hesitation/latency of response) Other specify:

Day 1 Normal

SPEECH Day 2 Normal

Day 3 Normal

Day 4 Normal

Day 5 Normal

Normal Normal Direct response

Normal Normal Direct response

Normal Normal Direct response

Normal Normal Direct response

Normal Normal Direct response

Is client: (Check if present) Cooperative Uncooperative Warm/friendly Distant Suspicious Combative Guarded Aggressive Hostile Aloof Apathetic Other specify:

ATTITUDE Day 1 Day 2

Day 3

Day 4

Day 5

Is client: (Check if present) Elated Sad Depressed Irritable Anxious Fearful Guilty Worried

MOOD & AFFECT Day 1 Day 2

Day 3

Day 4

Day 5

10

Angry Hopeless Labile Mixed (anxious & depressed) Is Clients affect : Flat Blunted or diminished Appropriate Inappropriate/incongruent Other specify:

(Check if present)

Concrete Thinking Circumstantiality Tangentiality Loose Association Echolalia Flight of Ideas Perseveration Clang association Blocking Word Salad Derailment Others Specify:

THOUGHT PROCESS Day 1 Day 2

Day 3

Day 4

Day 5

Does client have: (Check if present) Delusions a. Grandiose b. Persecutory c. Reference d. Somatic Suicidal thoughts Homicidal thoughts If Homicidal, towards whom?

THOUGHT CONTENT Day 1 Day 2

Day 3

Day 4

Day 5

To people who 11

speaks bad to her Obsessions Paranoia Phobias Magical Thinking Poverty of Speech Others Specify: NOTE: Questions around suicide and homicide need to be direct. For instance, are you thinking of harming yourself/another person right now? (If another, who?) Clients will usually admit suicidal thoughts if asked directly but will not always volunteer this information. Any threat to harm someone else requires informing the potential victim and the authorities.

Is client experiencing: (Check if present) Visual Hallucinations Auditory Hallucinations a. Commenting b. Discussing c. Commanding d. Loud e. Soft f. Other Other Hallucination (olfactory/tactile) Illusions Depersonalization Others Specify:

PERCEPTUAL DISTURBANCES Day 1 Day 2

Day 3

Day 4

Day 5

MEMORY/COGNITIVE Day 1 Day 2 Orientation (YES/NO) a. Time b. Place c. Person Memory (Good/Poor) a. Recent b. Remote c. Confabulation (Y/N) Level of Alertness Yes Yes Yes Good Good No Good Yes Yes Yes Good Good No Good

Day 3 Yes Yes Yes Good Good No Good

Day 4 Yes Yes Yes Good Good No Good

Day 5 Yes Yes Yes Good Good No Good

Day 1

INSIGHT and JUDGMENT Day 2

Day 3

Day 4

Day 5 12

Insight (Awareness of the Aware Aware Aware Aware Aware nature of the illness) Judgment (Good/Poor) Good Good Good Good Good Impulse Control Good Good Good Good Good (Good/Poor) Concentration Good Good Good Good Good (Good/Poor) Attention (Good/Poor) Good Good Good Good Good Others Specify: NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help the client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion with: Tell me more. A less direct and more conversational tone at the beginning of the interview may help reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship.

ANALOGY Patient C symbolizes a house, a new built house. But like any other house, once the one foundation is removed, the whole house would fall apart. Like when a one pillar is removed in the house, its stability will no longer be the same as before. Compare this to patient Ks life, they started with a very good life. Good foods, good clothes and they almost get everything they want until everything slowly fall apart when their financial stability was shaken. They still able to survive but not the way it were before when their financial status was stable. Relate it to a house, the house will still stand, but not as stable as when the foundation was shaken. Then other aspects will affect the house stability, like the infestation of termites. The termites will slowly ingest the wood inside the house, breaking more the foundation of the house. Like what happened in Ks life, he was influenced by his peers to take drugs. His peers became parasites who infested his mind to do bad things like termites do which is devouring the wood inside the house. Then a house without care and maintenance would worsen its condition. Dust, bacteria, insects would inhibit the house and slowly destroy the house. Like in patient Ks life, his
13

siblings doesnt treat him as an older brother. He gets depressed so much and affect s his level of functioning. Then, an unstable house if hit by a storm would totally destroy foundation of the house. Like when patient K was hit in the head by someone, that incident totally lost his mind. The well structured house was slowly destroyed with different factors.

14

IV. Psychodynamics Schematic Presentation

BIOLOGIC FACTOR

Genetics

PSYCHOSOCIAL FACTOR

Infancy

Toddler

Preschool

School age

Adolescence

Trust vs. mistrust

Autonomy vs. shame and doubt

Initiative vs. guilt

Industry vs. inferiority

Identity vs. role confusion

Excessive trust was developed

overly achieved a sense of control or autonomy

Havent learned to managed conflict and anxiety; guilt was developed

Developed the sense of inferiority

Role confusion;(wrong choice of friends)

Young adult Intimacy vs. isolation

Developed isolation.

Neuroleptic malignant syndrome

15

Chronic (persistent) psychotic disorders

Chronic (persistent) psychotic disorders* - F29# (Clinical term: Schizophrenia Eu20). Includes schizophrenia, schizoaffective disorders, schizotypal disorder,

persistent delusional disorders, induced delusional disorder, other non-organic psychotic disorders *Chronic psychosis has become a pejorative term: persistent psychosis embraces the possibility of recovery.

Presenting complaints

Many patients will have an established history of psychosis; others, however, may be unknown to specialized services, particularly those with more insidious presentations or those who have disengaged or are homeless.

Patients may present with the following:

difficulties with thinking or concentrating (eg they think that the television is talking to them, or that their thoughts are being read)

reports of hearing voices or seeing visions strange beliefs (eg having supernatural powers or being persecuted) extraordinary physical complaints (eg strange sensations or having unusual objects inside their body)

problems or questions related to antipsychotic medication problems in managing work, studies or relationships physical health care problems (eg weight, respiratory or cardiac problems)
16

lack of energy or motivation and an inability to feel emotion Depression or suicidal thinking.

Families might seek help because of apathy, withdrawal, poor hygiene, or strange behaviour.

Diagnostic features

Persistent problems with the following features:

social withdrawal and/or poor social integration low motivation, interest or self-neglect disordered thinking (exhibited by strange or disjointed speech).

Periodic episodes of:

depression (co-existing depression is a common, and is sometimes a serious consequence of persistent psychosis; there is a serious risk of suicide)

agitation or restlessness bizarre behaviour hallucinations (false or imagined perceptions, eg hearing voices) delusions (firm beliefs that are often false, eg patient is related to royalty, receiving messages from the television, being followed or persecuted)

Intense fear, anxiety and distress.

17

Differential diagnosis and co-existing conditions

Depression - F32# (if low or sad mood, pessimism and/or feelings of guilt; comorbid depression is common).

Bipolar disorder - F31 (if symptoms of mania excitement, elevated mood, exaggerated self-worth is prominent).

Alcohol misuse - F10 or Drug use disorders - F11#. Chronic intoxication or withdrawal from alcohol or other substances (stimulants, hallucinogens) can cause psychotic symptoms. Patients with persistent psychosis might misuse drugs and/or alcohol.

Essential information for patient and family

Agitation and strange behavior can be symptoms of a mental disorder. Symptoms may come and go over time. Medication should be part of an overall holistic and multi-axial approach to care and can help by reducing current difficulties and the risk of relapse.

Stable living conditions (eg stable accommodation, adequate income, daily work or activities) are a pre-requisite for effective rehabilitation and recovery.

It is important for family/careers to work with the doctors to learn to recognize early warning signs of relapse and for an advance agreement to be established with the patient and family/careers on how crises should be managed. (see Early warning signs form)

Voluntary organizations can provide valuable information, support and selfmanagement courses to the patient and careers
18

General management to patient and family Remain optimistic and emphasize the patients strengths and abilities rather than deficits. Recovery often takes place in small steps and, for the patient, being engaged in an activity that is meaningful to them might be as important as symptom control. Discuss a treatment plan with the patient, in line with NICE good practice; (ref 5) provides information on the condition, treatment choices and informed discussion. The treatment plan should include recognition of early warning signs and the agreed management of crises should be clearly recorded in the medical records. A copy of the plan should be given to the patient and, with their permission, to the family/career. Explain that drugs help prevent relapse, and discuss information on effects and side effects with the patient.(see Coping with the side effects of medication) The DVLA must be notified in all cases. Advise patient to inform DVLA: driving should cease until patient has been stable and well for at least three years and has insight into his/her condition (LGV/PSV driver) (ref 3) Support patient to function in the areas that are important to him/her (eg work, recreation, relationships). It is important proactively to offer patients the same health promotion and prevention measures as the general population (eg smoking cessation, weight control, screening for diabetes and sexual health). Substance misuse (seen in over 30% of cases) will increase the chance of relapse.

19

Psychological therapies for both the patient and family/careers might help prevent relapse, promote recovery, and are increasingly available in local services. Encourage the patient to engage with psychological therapies where available (eg cognitive behavioral therapy, family therapy, problem-solving interventions).

Family interventions or problem-solving work might help improve patient and career health.

Therapeutic alliances build on respect and feeling valued. Encourage the patient to build relationships with key members of the practice team, for example by seeing the same doctor or nurse at each appointment. Use the relationship to discuss the treatment plan including medication advantages of medication and to review the effectiveness of the care plan (see Social and living skills checklist).

Refer to Acute psychotic disorder - F23 for advice on the management of agitated or excited states.

If care is shared with the Community Mental Health Team, agree who is to do what.

Support of the career is essential for effective treatment and rehabilitation. An assessment of the patients needs and those of the career (under the Careers Recognition and Services Act) can be requested from the local Social Services department.

20

Medication

Antipsychotic medication may reduce psychotic symptoms (BNF section 4.2.1). Some patients remain stable on the older medications (eg trifluoperazine, chlorpromazine). If effective and well tolerated, NICE guidance suggests the drug should be continued (ref 5). If ineffective or poorly tolerated, NICE guidance suggests an atypical medication should be considered (ref 5).

Atypical antipsychotics, for example olanzapine (510 mg a day) or risperidone (2-4 mg per day), should be considered as a first-line treatment (ref 5).

Inform the patient that continued medication helps reduce risk of relapse. In general, antipsychotic medication should be continued for at least one year.

The dose should be the lowest possible for relief of symptoms and effective daily functioning.

If, after team support, the patient is reluctant or erratic in taking medication, injectable long-acting antipsychotic medication could be considered in order to ensure continuity of treatment and reduce risk of relapse (ref 59). It should be reviewed at 4-6 monthly intervals, and a weight gain and physical annual heath check is essential to decrease the risk of cardiac and respiratory effects of medication and a sedentary lifestyle. Doctors and nurses who give depot injections in primary care need training to do so (ref 60). If available, specific counseling about medication is also helpful (ref 61). As part of the shared care plan, decide who is to contact the patient should he/she fail to attend an appointment.

21

Discuss the potential side-effects with the patient. Common motor side-effects, particularly with older antipsychotics, include the following:

Acute dystonias or spasms and parkinsonian symptoms (eg tremor and akinesia), which can be managed with antiparkinsonian drugs (eg orphenadrine [50 mg three times a day] ); (BNF section 4.9)

withdrawal of antiparkinsonian drugs should be attempted after 2-3 months without symptoms, as these drugs are liable to misuse and may impair memory.

Akathisia (severe motor restlessness) can be managed with dosage reduction, or betablockers (eg propranolol at 3080 mg a day) (BNF section 2.4). A change in medication might be necessary

Tardive dyskinesia is a particularly important side-effect for which to monitor. It is associated with longer-term use of traditional antipsychotic medication, is severely disabling and can be irreversible.

Other side-effects can include glucose intolerance, weight gain, galactorrhoea and photosensitivity. Patients suffering from drug-induced photosensitivity are eligible for sunscreen on prescription.

Avoid poly-pharmacy, particularly concurrent prescribing of typical and atypical antipsychotics, and prescribing in excess of BNF guidelines.

References

5 National Institute for Clinical Excellence. Schizophrenia: Core Interventions i.

22

23

Name of Drug

Date ordered

Classification

Recommen ded Dose & Frequency

Why given to patient in relation to the mechanism of action

Contraindication

Side effects/ Toxic effects/ Drug-drug interaction

Stability of the drug

Nursing Conside ration

Generic brand

Therapeutic

Pyoric and duodenal obstruction, myasthenia gravis, hypotension Hepatic or renal impairment Alcoholism Alzheimers disease
Agitated Blurred vision Constipation Dizziness Drowsine ss Light headedne ss Dry mouth Dry nose & throat Nausea Nervous Store in closed light resistant container at 1530oC (5986oC)

Check vital signs, specially BP before giving.

Biperidine

5/25/11

Anti-parkinson drug

Adults: 2 mg 3-4 times per day to maximum of 16 mg/day

Synthetic cholinergic tremor may increase as spasticity is relieved, slight respiratory & cardiovascular effects

Avoid activities that requires mental alertness

24

Dose/Frequen cy prescribed
2 mg 1 tab

Pharmacologic
Cholinergic blocking agents

Indication:
Parkinsonism Relief of symptoms of EPS

GI upset

25

Name of Drug

Date ordered

Classification

Recommen ded Dose & Frequency

Generic brand

Therapeutic

Why given Contraindication to patient in relation to the mechanism of action Comatose, severely depressed state Circulatory collapse Liver damage CAD
Has significant anti-emetic hypotensive and sedative effect

Side effects/ Toxic effects/ Drug-drug interaction

Stability of the drug

Nursing Consideration

Chlorpromazine

5/25/11

Anti-psychotic

Adults: 100 mg 3 to 4x per day or 2-3 times per day

Dose/Frequen cy prescribed

Pharmacologic

Indication:

Constipation Drowsiness Blurred vision Decreased sweating Tremor Difficulty urinating Dark urine Dizziness Increase appetite Swollen breast

Avoid alcohol and any other CNS depressan ts Avoid temperature extremes

26

 Schizophrenia 100 mg 1 tab HS

Name of Drug

Date ordered

Classification

Recommen ded Dose & Frequency

Generic brand

Therapeutic

Why given Contraindication to patient in relation to the mechanism of action Comatose, severely depressed state Circulatory collapse Liver damage CAD

Side effects/ Toxic effects/

Stability of the drug

Nursing Conside ration

27

Fluphenazine

5/25/11

Anti-psychotic

Adults; 12.5-25 mg (0.5-1ml)

Anticholinergic effects

Drowsiness Dizziness Lethargy Nausea Anorexia Blurred vision Dry mouth Constipation

Store at room temperat ure and avoid freezing the elixir

Dose/Frequen cy prescribed
1.0 mL deep IM

Pharmacologic
Dopaminergic Bocker

Indication:
Psychosis disorder Schizophrenia

Avoid activities that requires mental alertness until drug effects takes place Period tubs, hot shower, and baths as low BP may occur Avoid alcohol, CNS depressan ts and OTC drugs or cough remedies

28

Name of Drug

Date ordered

Classification

Recommen ded Dose & Frequency

Why given Contraindication to patient in relation to the mechanism of action

Competitively blocks the effects of histamine at H1- receptor sites, has atropine-like, anti-pruritic, and sedative Indication: effects

Side effects/ Toxic effects/

Stability of the drug

Nursing Conside ration

Generic brand
Diphenhydramin e

Therapeutic
Anti-histamine Adults: 25 -50 mg PO 3-4 times per day

Younger than 5 years old

Dose/Frequen cy prescribed
1 tab at H.S.

Pharmacologic
H1 receptor antagonist

Night time sleep aid

Asthesia Constipation Dizziness Diarrhea Drowsine ss Headach e Dry mouth Dry nose & throat Nausea & vomiting Nervous GI upset

Store in closed light resistant container at 1530oC (5986oC)

Avoid the use of alcohol and any other CNS depressan ts

29

Nursing Diagnosis: Dysfunctional family processes r/t lack of problem solving skills. Cause analysis: psychosocial and physiological function of the family unit are disorganized, which leads to conflict, resistance to change, ineffective problem solving and series of self perpetuating crises. Cues Subjective: makalagot jud kayo ang akong mga igsoon kay dili agpatoo sa ako. Planning Intervention Rationale Maximizes understanding of what is expected to each individual. Evaluation Lto: At the end of 3 days, the pt: Participate d in individual treatment programs. Took some actions to change behaviors that contribute to clients substance abuse. Goal was partially met

Objectives: Inappropriate expression of anger; blaming, criticizing Triangulating family relationships Inability to adapt change; inability to deal constructivel y with traumatic experiences.

Lto: At the end of 3 days, the pt will: Participate in individual treatment programs. Take action to change behaviors that contribute to clients substance abuse.

Sto: At the end of 8 hours, pt will: Verbalize understand ing of dynamics of codepende nce

Review family history, explores roles of family members and circumstances involving substance abuse. Mutually agree on behaviors/resp onsibilities for nurse and client. Provide information regarding effects of addiction on mood/personali ty of the involved person. Identify use of manipulative behaviors and discuss ways to avoid/prevent these situations.

To enhance the therapeutic relationship.

Helps family members understand and cope with negative behaviors without being judgmental or reacting angrily. Manipulation has the goal of controlling others and when family members accept self responsibility and commit to stop using it, new healthy behaviors will ensue.

Sto: At the end of 8 hours, pt: Verbalize d understan ding of dynamics of codepend ence. Goal met. was

30

Previous lifestyle/relatio nships supported substance abuse use, requiring change to prevent Collaborative: relapse. 1. Encourage 1. To provide involvemen ongoing t to selfsupport and help assist with groups. problem 2. Provide 2. To promote bibliotherap wellness. y as appropriate .

Discuss the importance of restructuring life activities, work or leisure activities.

31

Nursing diagnosis: Ineffective coping r/t difficulty handling new situations. Cause analysis: inability to form a valid appraisal of the stressors Cues dili jud namu madawat ang nahitabo sa amu papa nga nahimo sya nga naa sa construction worker gikan sa iyang pagkasupervisor sa companya. Objectives: Destructive self behavior towards self (use of drug abuse) Behavioral changes (e.g., frustration, discouragement, irritability, impatience) Use of forms of coping that impede adaptive behavior(includi ng inappropriate use of defense mechanisms, verbal manipulation). Planning Lto: At the end of 5 days, the pt will: Meet psychologic al needs as evidenced by appropriate expressions of feelings, identification of resources. Assess the current situation accurately. Sto: Intervention 1.Evaluate ability to understand events, provide realistic appraisal of situation. 2. Note speech and communicating patterns and observe behaviors in objective terms. 3.explain disease process/proced ures/in a simple concise manner. Rationale Evaluation

4. confront client when behavior At the end of 2 is inappropriate, pointing out days, pt will: differences Verbalize between words feelings and actions. congruent 5. treat client with with courtesy behavior and respect. Verbalize Converse at awareness level, of own clients providing coping meaningful abilities. conversation while performing care. 6. Help client how to

1. to Lto: determine degree of At the end of impairment. 5 days, the pt: Meet psycholog 2. To validate ical needs data according as to what pt. evidenced assert by compare to appropriat how pt .act. e expressio 3. may help to ns of express feelings. emotions, Assess grasp the situation, and current feel more in situation control. not so 4.provides accurate. external locus of control, Goals were enhancing met. safety. Sto: At the end of 5. enhances 2 days, pt: therapeutic Verbalize relationship. feelings congruent with behavior Verbalize awarenes s of own coping 6. Provide abilities. opportunity to
32

substitute increase pt. goals positive self esteem. met. thoughts for negative ones. Collaborative: 1. Refer to a therapist as appropriate. 2. give information about purposes, side effects of medications and treatments.

was

1. To discuss pt.s concerns. 2. Makes the patient feel importance.

33

Nursing diagnosis: ineffective role performance r/t inadequate support system Cause analysis: patterns of behavior and self expression that do not match the environmental context, norms and expectations. Cues Subjective: Ang akong mga igsoon dili ko gapaminawun, burag dili ko nila maguwang, as verbalized by the patient. Planning Intervention Rationale Evaluation At the end of 5 days, pt: Develop some realistic plans for adapting to role changes. Goal was partially met. At the end of 3 days,pt: Verbalize d understan ding of role expectatio ns and obligation s

At the end of 5 days, pt will: Develop realistic plans for adapting to role changes. At the end of 3 days, pt. will: Objectives: Verbalize Inadequate understandin external g of role support for expectations role and enactment obligations. System conflict Inadequate adaptation to change.

1. determine 1. To client assess perceptions/co patients ncerns about feelings situation. about situation. 2.maintain 2. To positive attitude promote toward the client. clients comfort. 3.provide 3. enhaces opportunities for self the client to concept exercise control and over as many as promotes decisions as commitm possible. ent to goals. 4.use the 4. To cope techniques of role with rehearsal to help changes. the client develop new skills. 5. make 5. Provides information opportuni available for client ty to be to learn about role proactive expectations/dem in dealing ands that may with occur. changes. Collaborative: 1. Interview SO(s) 1. may regarding their influence perceptions clients view and of self. expectations. 2. provides 2. Refer to ongoing

34

support support to groups, sustain counseling and progress. psychotherapy, as appropriate.

35

Nursing diagnosis: disturbed thought process r/t drug abuse. Cause analysis: effect of the substance abuse that results to a disturbed thought process. Cues Subjective: pirmi ko kadungog sa mga music nga kusog kayo, ganahan ko maminaw. Planning Intervention 1.assess attention span and distractibility and ability to make decisions or problem solve. 2.test ability to receive, send and appropriately interpret communicatio n 3.note behavior such as untidy personal habits and slurred speech. Note occurrence of paranoia and delusions 4. orient the pt. to person, place and time. Rationale 1.determines ability to participate in planning/execut ing care. Evaluation

Lto: at the end of 5 week, the pt will: Maintain usual reality orientation Objectives: Demonstrat hallucinations e behaviors Inappropriate that will interpretation of minimize/pr stimuli event changes in Distractibility mentation Hypervigilan Identify ce intervention s to deal effectively with situation. Sto: At the end of 2 days, the pot will: Verbalize understandi 3. ng of causative factors.

Lto: at the end of 5 week, the pt will: Maintain usual reality orientation 2.to assess Demonstrat degree of e behaviors impairment. that will minimize/pr event changes in mentation 3.Indicates Identify severity of intervention illness. s to deal effectively with situation. Goal was met

Sto: At the end of 2 days, the 4.to see pts pot will: cognition and Verbalize assessment of understanding current situation of causative factors. 5.have the 5.for client write comparison name purposes. periodically. 6.reduce 6.To avoid the provocative fight and flights
36

stimuli, negative criticisms, arguments and confrontations . Collaborative 1. assist in identifying ongoing treatment needs for the pt. 2. promote socializatio n within individual limit. 3. Refer to appropriate rehabilitatio n provider.

response

1.to maintain gains and continue progress.

2.to promote wellness.

3.to have continuous approach care.

a to

37

Nursing diagnosis: risk for others directed violence r/t history of violence against others. Cause analysis: at risk for behaviors in which the individuals demonstrate that he can be physically harmful to others. Cues Subjective: nakapatay ko sa una og tao kay ila man ko gipareglahan, nanimalos ko sailing gibuhat ako syang gidunggab, as verbalized by the patient. Planning Lto: At the end of 5 days, pt will: Participate in care and meet in own needs in an assertive manner. Acknowle dge realities of the situation Demonstr ate self control as evidenced by relaxed, non violent behavior. Intervention 1. ascertain clients perception of self and situation. 2. observe/listen for early signs of distress increasing anxiety(irritabili ty, lack of cooperation). 3.ask directly if the person is thinking on acting thoughts/feelin gs. 4.assess client coping behavior already present. Rationale Evaluation

Objectives: Family background(c onflict, chaotic) Directing angry messages and disappointme nts at a significant others who has rejected the patient. Sto: Emotional problems(ang At the end er) of 8 hours,pt will: Verbalize understan ding of why behavior

1.to assess the Lto: situation. At the end of 5 days, pt will: Participated in care and meet 2.May indicate in own needs possibility of in an assertive loss of control manner. and Acknowledged intervention at realities of the this point can situation prevent a blow Demonstrated up self control as 3.to determine evidenced by violent intent. relaxed, non violent behavior. Goals were met. Sto: At the end of 8 hours, pt will: Verbalized understand ing of why behavior occurs Goal was met.

4.client believes that there are no alternatives other than violence. 5.develop a 5.promotes therapeutic sense of trust nurse-client allowing relationship. clients feeling Provide to discuss consistent openly. caregiver when possible. 6.be truthful in 6.builds trust dealing with and enhancing client and therapeutic

38

occurs.

giving information 7.give positive reinforcements for clients behaviors. Collaborative: 1.prescribed antipsychotic medications.

relationship. 7.encourages continuation of desired behaviors.

1.the chemistry of the brain is changed by early violence and had been known to respond to serotonin, as well as related neurotransmitt ers system, which play a role in restraining aggressive impulses. 2.discuss 2.to maximize clients reason plan of care of behavior so significant others. Determine desired commitment of involved parties to sustain current relationship. 3.identify 3.those around support him need to systems(family learn how to , friends) be positive role models and display a broader array for resolving problems

39

Discharge Planning Exercise o Encourage client to exercise every day for at least 30 mins, preferably early in the morning. This is to stimulate blood circulation in the body, move and exercise muscles and joints. Medication o Patient should be instructed to take medication regularly at the right time and a right dose. Foods o Certain foods should be avoided this is to prevent aggravating the patients mood like foods containing caffeine, like colas, sodas, cakes, sweets and chocolates. Support system o Provide support for decision to stop substance use. o Promote family involvement in rehabilitation program. o Plan to maintain substance-free life formulated.

40

Prognosis and Recommendation Recommendation for Mr. K is to encourage him to do morning care and take his prescribed medications properly. Continue exercise and eat nutritious food and avoiding foods like energy drinks, caffeine beverages and chocolates. Encourage him to participate in any therapy that well enhances his knowledge.

A. criteria for prognosis basing from the following: a. Onset of illness: b. Duration of illness: c. Precipating factors: d. Mood and Affect: e. Attitude towards taking medication: f. Any depressive feature: g. Family support: Fair Poor Poor Good Good None Poor

Resident K prognosis overall is fair because as you can see at the tabulation onset of illness is fair because his illness was detected early because he manifested symptoms. The duration of illness is poor because he started this illness at the age of 16. And for Precipating factors is poor because of their socioeconomic situation. For attitude towards taking of medication is good because he took his prescribed drug on

41

time. And for the family support, its poor because no one ever visited him at St. Dymphna for quite a long time now, not even by his family. Nurse-Resident-Interaction: Day # 1 Physical Description of the Client: Client appears happy but grooming and hygiene is poor. Physical Description of the Setting: Setting is within the clients room. Objective: Nurse maayong buntag, kumusta man ka? Therapeutic Communication Done Giving recognition Resident maayong buntag mga maam, Kendal akong ngalan as verbalized by the client. maulaw man ko ninyoas verbalized by the client. naa diri o, naa sila duha nagtinan-awa silaas verbalized by client. Interpretation/Analysis

To indicate awareness.

pwede istoryahan ko nimu mahitungod sa imung kaugalingon? wala may tao diha sa imung kamot

Exploring

To examine the issue more fully.

Presenting reality

To indicate what is real.

Giving information ako si Maam Lovely Grace. mura man ka ug naulaw?

Giving information builds trust with the client. Sometimes client cannot verbalize or make themselves understood. So that the client does not have to respond verbally to get the nurses attention.

Making observation patient nodded and repeats my name.

Offering self kung naa kay mga gusto nga iistorya pwede ka muistorya sa amua.

Patient smiles

Silence

Patient smiles with Encourages the client to good eye contact. verbalize provided that
42

.. General leads sige padayon, unsa pa man? Placing event in time kanus-a mani nahitabo? unsa nga patay. Accepting nodding gipatay naku sa akong hunahuna. Client went on telling his experiences.

is interested and expectant. Indicates that the nurse is listening and following.

Translating into feelings

To see some things that client continues to is not related. talk. To understand the clients word. high school pa ko. To indicate that the nurse has heard and followed the train of thought.

43

Nurse-Resident-Interaction: Day # 2 Physical Description of the Client: Client is sweaty looks anxious. Physical Description of the Setting: setting is inside the room together with other clients and student nurses. Objective: Nurse Good morning Kendal. naa kay gusto iistorya? unsay nahitabo man? Unsa man imung gibati nga nagtherapy ka? gasinguta man lage ka kendall? wala may mapa diha kanang imu nakita dili na tinuod. Therapeutic Communication Done Giving recognition Resident Good morning as verbalized. No response Interpretation/Analysis

To indicate awareness.

Broad opening

Stimulate the patient to take the initiative. To relieve the tension the client is feeling.

Encouraging description of perceptions Encouraging expression

No response

Smiling

Encourages the client to make his own appraisal rather than to accept the opinion of others.

Making observations

igang man kauas To make the self of the verbalized by the client be understood. client. toa o Luzon, toa ang visayaas verbalized. To indicate what is real.

Presenting reality

44

Nurse-Resident-Interaction: Day # 3 Physical Description of the Client: client has unusual movements and appears clean and well-groomed. Physical Description of the Setting: inside the administration room sitting on chair with client facing us. Objective: to gather necessary information/data and know what other factors that is bothering the client and what is his past experiences and to build rapport. Nurse Good morning Kendal. Therapeutic Communication Done Giving recognition Resident Good morning with matching smile as verbalized. Client shared stories about his past life. Client continued telling his stories. Client continued telling his stories. Smiling. Interpretation/Analysis

To indicate awareness.

istoryahe mi sa imung mga kaagi? Nodding. sige padayon. unsa man imung gibati mahitungod sa atong therapy? naa kay gusto iistorya? unsa man imu pasabot dana?

Exploring

To examine the issue more fully.

Accepting General leads

To indicate that nurse has followed the train of thoughts.

Encouraging expressions

Encourages the client to make his own appraisal rather than to accept the opinion of others. Stimulate the patient to take the initiative.

Broad opening

No response just having physical movements. wala man koy pasabotas verbalized.

Encouraging description of perception.

To relieve the tension the client is feeling.

45

Nurse-Resident-Interaction: Day # 4 Physical Description of the Client: client appears clean but smells bad. Physical Description of the Setting: we stayed in the administration office. Objective: Nurse Good morning Kendal. unsa man imung gibati sa therapy? Therapeutic Communication Done Giving recognition Resident Good morning as verbalized with matching smile. mayo nalingaw ko kay nakadaug mi tungod naku as verbalized. Client continued his drawing. Interpretation/Analysis

To indicate awareness.

Encouraging expression .

Encourages client to make his own appraisal rather than to accept the opinion of others. To indicate that nurse has followed the train of thoughts. To indicate that the nurse listened and followed. To make the self of the client be understood. To indicate what is real.

nodding.

Accepting

sige padayon

General lead

Client continued his drawing.

gasinguta man lage ka? wala man mi nakita sa imung kamot (palad).

Making observations Presenting reality

Silence. sa imu wala man pero sa akoa naa as verbalized.

46

47

Bibliography Nursing drug guide, Karch, Amy M.,Lippincott William & Wilkins(2009) Psychiatric mental health nursing, Videbeck, Sheila L.,5th Edition, Lippincott William & Wilkins (2011) Nurses Pocket Guide, Doenges, Marilyn et.al, 11th edition,LA Davis Company (2008) Diagnostic and statistical Manual of Mental disorders-TR, 4th Edition,Washington DC, American Psychiatric Association (2000) Medical-surgical nursing,Black, Joyce M. & Hawks, Jane Hokanson, Eight edition,Elsevier, Inc (2009)

http://www.mentalneurologicalprimarycare.org/ 3 Driver and Vehicle Licensing Agency. At a Glance Guide to Medical Aspects of Fitness to Drive. URL http://www.dvla.gov.uk. Further information is available from The Senior Medical Adviser, DVLA, Driver Medical Unit, Longview Road, Morriston, Swansea SA99 ITU, Wales. 5 National Institute for Clinical Excellence. Schizophrenia: Core Interventions in the Treatment

48

and Management of Schizophrenia in Primary and Secondary Care. Clinical Guideline 1. December 2002. URL http://www.nice.org.uk. (AI)

49