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S O A P I

Galit ako sa mga nurse, nagpapaka nurse, mga nurseses. As verbalized by the patient Anger towards the students nurses, jealous, suspicious, irritable Risk for Injury related to lack of control over emotions After 3 visits the clients family will learned measures to protect JT from injury 1. Taught family members to constantly check the surrounding environment for materials that can be used for inflicting injury. 2. Emphasized the importance of medication compliance.

3. Provided structured schedule of activities that includes established rest periods throughout the day 4. Discussed the disease process to all individuals within the household.

5. Administered 1 tablet Fluoxitine Hcl 10mg OD, PO On the last visit the live in partner procure ordered medication and was administered to JT

S hindi talaga ako makatulog sa gabi. As verbalized by the client O -Inability to sleep at night -Easily awakened -Upon awakening client exhibits lethargy, fatigue, weakness A Sleep Pattern Disturbance related to agitation P Short term: At the end of the visit JT and live in partner will understand the importance of taking in ordered home medication

Long term: At the end of 5 visits client will verbalize continuous sleep of at least 6-8hrs I 1. 1. Encouraged to perform relaxation techniques like listening soft music 2. 3. 2. Taught client and live in partner drug mechanism of action and measures that

promote sleep, such as warm, non-stimulating drinks, light snacks, warm bath, back rubs 4. 5. 3. Instructed to avoid caffeinated drinks, such as tea, coffee, and colas 6. 4. Instructed to administer antidepressant medication at bedtime, as prescribed by the physician E On the fifth visits JT was asleep and had just taken the prescribed antidepressant

S ayokong maglakad mag isa kasi nasa likod si God, pinaparemind niya ako sa mga kasalanan ko As verbalized by the patient O A Altered thought processes related to biochemical alteration P Short term: At the end of 1 home visits client will be able to distinguish false belief from reality - Delusional thinking(false ideas) - inappropriate social behavior - impaired ability to make decisions, problem-solve, reason

Long term: At the end of 5 visits JT will no longer experience delusional thinking I 1. 1. Did not argue or deny the belief. Used reasonable doubt as a therapeutic technique 1. 2. Helped client try to connect the false beliefs to times of increased anxiety. Discussed techniques that could be used to control anxiety (e.g., deep breathing exercises, other relaxation techniques, thought stopping techniques) 2. 3. Reinforced and focused on reality. Discouraged long ruminations about the irrational thinking. Talk about real events and real people 3. 4. Listened to client in her attempt to verbalize feelings of anxiety, fear, or insecurity 4. 5. Administered 1tablet of Flouxetine Hcl 10 mg, OD, PO On the third visit JT did not mention about her delusional thinking

S Wala talaga akong ganang kumain. As verbalized by the patient O A - Poor muscle tone - Loss of weight - Pale conjunctiva and mucous membranes Altered nutrition less than body requirement related to lack of interest in food P Short term: At the end of 1 visit JT will consume 1 serving of food

Long term: After 5 visits JT and family will understand the importance of adequate food intake I 5. 1. Explained the importance of adequate nutrition and fluid intake 2. 2. Determined clients foods idiosyncrasies 3. Health teachings imparted with emphasis on: - Increase intake of nutritious foods such as green leafy vegetables and fruits - Increase intake of foods rich in protein in diet - Increase intake of foods rich in Vit. C for immune resistance 6. 4. Encouraged have juice and snacks available on the unit at all times 6. 5. Encouraged to take vitamins and food supplements E At the end of 1 home visit objectives were not met but client was able to express improved appetite

S ayokong mag lakad mag isa kasi sumusunod sa akin si God, pinaparemind niya ako sa mga kasalanan ko. As verbalized by the client O Seeks refuge in church when feeling overwhelmed Unable to distinguish helping desires from plain inquiry Client refuses medication administration with the belief that it will make her condition Sensory perceptual alteration related to sleep deprivation P Short term: At the end of 1 visit client will be able to distinguish reality against delusion Long term: At the end 5 visits client will be able to define and test reality, decrease the occurrence of sensory misperception I 7. 1. Distracted client from elaborating delusional thinking 8. 2. Showed an attitude of acceptance to encourage the client to share content of the hallucination/delusion with the nurse 3. 3. Did not reinforce the delusion 4. 9. 4. Tried to connect the times of misperception to times of increased anxiety. Helped client to understand this connection 5. 5. Administered 1tablet of Flouxetine Hcl 10 mg, OD, PO E At the end of 1 visit client was able to distinguish reality against delusion

S Dili ko ganahan mo inom anang tambal kay mabuang kog samot. As verbalized by the patient O A Knowledge deficit related to medication regimen P Short term: At the end of 2 home visits client will be able to verbalize understanding about medication regimen - Refuses medication administration believing that could make her condition worse - Does not have any comprehension on reason why been brought to the institution - Misconceptions about relationships

Long term: At the end of 5 visits JT will be able to comply medication prescribed I 7. 1. Assessed clients level of knowledge regarding positive self-care practices and readiness to learn 2. Determined method of learning most appropriate for the client (discussion) 3. Provided information regarding healthful strategies for activities of daily living 4. Discussed the importance and adverse effects of medication and its management 6. 5. Advised family to

At the end of 5 visits patient was able to take in medication prescribed and understand the importance of medication regimen.

S O

No subjective cues - Becomes overly emotional when topic about mother becomes discussed - Becomes overly emotional when topic about previous partner was discussed - Displays aversion when asked about mother and children Dysfunctional grieving related to feelings of guilt generated by ambivalent relationship with lost concept

Short term: At the end of 3 home visits client will express anger toward lost concept

Long term: At the end of 5 visits client will be able to verbalize behaviors associated with the normal stages of grief I 10. 1. Determined stage of grief in which client is fixed. Identify behaviors associated with this stage 2. Developed a trusting relationship with the client. Showed empathy and was caring. 8. 11. 3. Conveyed an accepting attitude, and enable the client to express feelings, openly 12. 4. Encouraged client to express anger. Assisted client to explore angry feelings so that

they may be directed toward the intended object or person 13. 5. Taught normal stages of grief and behaviors associated with each stage. Helped client to understand that feeling such as guilt and anger toward the lost entity are appropriate and acceptable during the grief process E At the end of 5 visits objectives were not met due to limited time allotted and unavailability to create interaction.