CUES SUBJECTIVE: Nurse: Gumamit po ba kayo ng mga ipinagbabawal na gamot?

(open-ended question) Patient: Hinde, yun ang isang bagay na ipinagmamalaki ko. OBJECTIVE: -General appearance -Euthymic Affect -Well-groomed -Good posture -Good eye contact -Appropriate facial expression -Motor Behavior -Fine hand tremors -Sensory and Cognition -Good thought process

PSYCHIATRIC NURSING DIAGNOSIS Defensive coping related to disturbance in pattern of appraisal of threat

PSYCHODYNAMICS The patient was unable to perform a valid appraisal of the stressor, inadequate choices of practiced responses, and inability to use available resources. It is also characterized by repeated projection of falsely positive selfevaluation based on a self-protective pattern that defends against underlying perceived threats to positive selfregard.

GOALS AND OBJECTIVES

THERAPEUTIC APPROACH

RATIONALE

EVALUATION

After 4 hour of INDEPENDENT: nursing intervention the >Develop therapeutic patient will be able relationship with the client to:

After 4 hour of nursing intervention the patient >to allow client to was able to: talk freely about feelings and concerns > demonstrate increase (Nurses Pocket Guide, 10th understanding to self
edition)

> demonstrate increase >identify ineffective >to note how these understanding to >Determine coping coping behaviors and its behaviors affect self mechanism being used consequences current situations
(Nurses Pocket Guide, 10th edition)

>identify ineffective coping behaviors and its > Ignore or withdraw your consequences attention from the defensive coping behavior being >verbalize projected (Psychiatric-Mental Health awareness of own Nursing 5th edition) coping abilities >verbalizes feelings congruent to behavior >meet psychological needs as evidenced by appropriate >convey attitude expression of acceptance and respect feelings

>verbalize awareness of own coping abilities >verbalizes feelings congruent to behavior >meet psychological needs as evidenced by appropriate expression of feelings

> It is important to minimize attention given to unacceptable behaviors. Withdrawing attention can be more effective than negative reinforcement in decreasing unacceptable behavior.
(Nurses Pocket Guide, 10th edition)

of

>to avoid threatening clients self concept, preserve existing self esteem
(Nurses Pocket Guide, 10th edition)

> Give the client positive > Positive feedback

feedback appropriate.

whenever provides reinforcement for the clients growth and can enhance selfesteem. It is essential to support the client in positive ways and not to give attention only for unacceptable behaviors.
(Nurses Pocket Guide, 10th edition)

>encourage the client to try >it provides new coping behaviors and understanding of gradually master the client to self and situation helps the client to have a different and more effective way to cope in stressors and threats
(Nurses Pocket Guide, 10th edition)

COLLABORATIVE: > Let the patient have his >A person with a talk therapy. (referral) different perspective on the situation can help the patient decide how to fix the problems they are having, and how to deal with the things they cant fix. Through discussion, the patient can find ways to handle their problems so that the same issues wont

continually his life.

disrupt

(Nurses Pocket Guide, 10th edition)