Case Study Psychiatric

1 Psychiatric Nursingcasestudy.blogspot.com 2 I. Introduction Whatever happened to Rizal’s famous quote “The youth is the hope of the nation” when a large percentage of the youth today are into intoxicating drugs and substances? These “future leaders” have indulged themselves into vices that are slowly killing them and destroying their bright future, the country’s bright future. Through sniffing and injecting cocaine the enjoyed a few minutes of ecstasy but unknowingly they have let in a poison run through their veins destroying them from the inside. By the time they realize ( if ever they do) what’s happening, it is usually too late to repair the damage done. This is a case of twenty-year old Ms. April Mechelle Tecson, a resident of Brgy. Camputhaw, Cebu City who, like the youths mentioned above, got herself into an addictive vice like sniffing cocaine and injecting it into her own vein. She’s been using it for nearly five years, realized last June that it wasn’t really doing her any good, stopped, made a narrow escape from the cocaine’s deadly consequences but otherwise suffered from its common withdrawal effect: psychosis. A substance-induced psychotic disorder, by definition, is directly caused by the effects of drugs including alcohol, medications and toxin. Psychotic symptoms can result from intoxication on alcohol, amphetamines, cocaine and inhalants or as a result of withdrawal from the mentioned substances. 3 The disorder is categorized in two ways. First, it is subtyped based on whether the prominent feature is delusion or hallucination. Hallucinations are seeing, hearing, feeling, tasting or smelling things that are not there and delusions are fixed, false beliefs. Second, it is subtyped based on whether it began during intoxication on a substance or during withdrawal from a substance. A substance-induced psychotic disorder that begins during substance use can last as long as the drug is used while a psychosis that begins during withdrawal may first manifest up to four weeks after an individual stops using the drug. April Mechelle Tecson’s case is an interesting and controversial one. Interesting in a sense that the student nurse is about the client’s age and it brings up the possibility of finding an answer to the question: What could possibly have lead those youths to bring about their own destruction? Controversial in a way because it involves a prominent issue such as drug addiction and gives rise to questions such as: What is the government doing to control these stuff and why are drug dens ( Kamputhaw is a famous one), even though everybody knows where they are, still impregnable to authorities? This case study aims to shed light on, as much as possible, all of the factors that have lead to April Mechelle Tecson’s current state of health. As her student nurse and as someone who has sentiments over a co-youth who have gone astray, the author seeks to delve more on here case and find means to help her and her significant others deal with the disorder substance-induced psychosis. 4 II. Objectives General Objectives: This case study aims to help the student nurse in effectively providing holistic caring care for a patient suffering from substance-induced psychosis. It also aims to aid the patient in coping with life situations, and incorporating it into her reorientation to reality and activities of daily living for her optimum level of functioning. Specific objectives: After 2 weeks of providing holistic caring care and facilitating student nurse-patient interaction, the student will be able to : 1. perform a thorough assessment of an adolescent in her present condition, and discuss the physical, social and cognitive characteristics of an adolescent, 2. establish rapport and interact with the patient at the patient’s own level and taking into consideration her present condition 3. identify the signs and symptoms presented by the patient in relation to the disease process 4. implement a comprehensive plan of care for the patient with substanceinduced psychotic disorder, and 5. evaluate the interventions provided in the given span of time for efficiency and effectiveness. 5 After 2 weeks of receiving holistic caring care, and participating in student nurse-client interaction, the client and her significant others will be able to: 1. establish trust towards the student nurse 2. cooperate in procedures performed to the client for management and treatment, such as adhering to the medication regimen, 3. participate with the student nurse in activities aimed at the patient’s holistic well being, such s in art therapy and morning stretching exercises, 4. manifest signs of reorientation to reality, and 5. terminate the therapeutic student nurse-client interaction at the end of the given span of time 6 III. Nursing Assessment 1. Personal History 1.1 Patient’s profile Name: Age: Sex: Civil status: Religion: Tecson, April Mechelle Marson 20 years old Female Single Roman Catholic Date of admission:September 8, 2007; 9:00 pm Room No.: XII Complaint: “nanggukod ug kutsilyo sa silingan”,as verbalized by mother Impression/Diagnosis:Substance-induced psychosis Physician: Dr. Yazar 1.2 Family and Individual information, social and health history April Mechelle Tecson, 20-year old and single, was admitted by her father, Ariel Tecson at Vicente Sotto Memorial Medical Center Psychiatry ward at around nine in the evening. Client belongs to a low socioeconomic class family and is the eldest among three siblings. She is a known alcoholic and cocaine abuser and a cigarette smoker. Hours prior to admission, client was seen running after a pregnant neighbor with a knife in her hand. 7 Client was formerly enrolled at Abellana High School but stopped when she reached second year high school. She was known to have started using “shabu” injectables when she was fifteen years old. According to her mother, Mrs. Rosalie Tecson, client was noticed to have stopped taking the said the said drug last June and that’s when she started exhibiting the positive symptoms such as talking and laughing by herself. When confronted that she was acting weird, client responded angrily saying: “Ako man hinuoy praning! Di ko praning! Basin ikaw!”. Client’s family has a history of addiction and psychosis. Her mother’s brother was also addicted to marijuana and was admitted at VSMMC Psychiatry ward last 1980. Her father’s sister have had postpartum psychosis last 1989 which was known to be recurrent. She already got well but the condition returned last 1994. Factors thought to have influenced remission include the fact that she was a battered wife and her husband was always abroad and she was left with the responsibility of taking care of their only son who has cerebral palsy. Client’s medical history showed that client was admitted at Southern Island when she was still days old and was diagnosed to have had meningitis. Her mother expressed that it was probably due to the fact that April was delivered not in the hospital but in their house. Mrs. Tecson gave birth with the aide of a “manghihilot/mananabang” who follows certain beliefs/odd beliefs like having the baby taste her first feces as a form of “sumpa” against evil spirits. 8 When April Mechelle was fourteen years old, she was admitted by her boyfriend at North General Hospital due to massive bleeding. She was diagnosed to have uterine laceration. According to her mother, April Mechelle has only one bestfriend that she knows of. Her name was “Ilang” and April shares with her all her problems. Ilang was close to April’s mother so she can tell her what was going on with April. However, Ilang got married and transferred residence so April lost contact with her. Since then, Mrs. Rosalie Tecson was not able to get information regarding the goings on in her daughter’s life because April seldom talks to her about her feelings and concerns. Upon admission, client was time, person and place oriented, has an intact short and long term memory, with poor concentration and exhibited circumstantiality. She is currently prescribed Haloperidol 20 mg. ½ tab OD, Biperiden 2 mg. 1 tab OD and chlorpromazine 100 mg. 1 tab OD at hour of sleep. Client is for homicidal and suicidal precaution. 1.3 Level of Growth and Development 1.3.1 Normal Development at stage of adolescence (12-20 years old) The rate of a person’s growth and development is highly individual; however, the sequence of growth and development is predictable. Gowth and development are commonly thought of as having five major components: physiologic, psychosocial, cognitive, moral and spiritual. 9 On this case, the client, Ms. April Mechelle Tecson, 20 years old, is on the stage of an adolescence. She is specifically in the middle of being an adolescent and a young adult because according to Fundamentals of Nursing by Barbara Kozier, and adolescent’s age ranges from twelve up to twenty years old, while a young adult is twenty to forty years old. An adolescent’s self concept changes with biologic development. Values are tested, physical growth accelerates and stress increases, especially in the face of conflicts. Significant others should assist adolescents to develop their coping behaviors. Physiologic Development Physical changes occur rapidly in adolescence. Sexual maturation occurs with the development of primary and secondary sexual characteristics. Four main focuses of the physical changes are: 1. increased growth rate of skeleton, muscle and viscera 2. sex-specific changes, such as changes in shoulder and hip width 3. alteration in distribution of muscle and fat 4. development of the reproductive system and secondary sex characteristics Wide variation exists in the timing of physical changes associated with puberty between sexes and within the same sex. Girls tend to begin their physical changes earlier than boys. April have had her menses at the age of 11. 10 Height and weight increases usually occur during the prepubertal growth spurt. The growth spurt for girls generally begins between 8-14 years of age. Height increases 2-6 inches and weight increases by 15-55 pounds. The final 20 % to 25% of adult height and 50% of adult weight is gained during this time period. The client’s build is within the normal range. The client’s height is 5’1’’ and weight is 120 lbs. Developmental Task Theories According to Robert Havighurst, growth and development occurs during 6 stages, each associated with 6-10 tasks to be learned. April is in the stage of adolescence and the tasks are as follows:  achieving emotional independence from parents and other adults  achieving assurance of economic independence  selecting and preparing for an occupation  preparing for marriage and family life  developing intellectual skills and concepts necessary for civic competence  desiring and achieving socially responsible behavior  acquiring a set of values and ethical system as a guide to behavior  Psychosocial According to Sigmund Freud 11 Client is at genital stage wherein energy is directed towards full sexual maturity and function and development of skills needed to cope with the environment. Separation from parents, achievement of independence and decision making are encouraged. According to Erik Erickson Erickson envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can either be complete, partial or unsuccessful. April is at the adolescence stage ( 12-20 y.o.) with a central task identity vs. role confusion. A coherent sense of self and plans to actualize one’s abilities are indicators of a positive resolution for this stage. According to Roger Gould Gould believes that transformation is a central theme during adulthood. 20’s is the time when a person assumes new roles. April is at stage 2 ( 18-22 y.o.). According to Gould, at this stage, although the individuals have established autonomy, they feel it is in jeopardy. They feel they could be pulled back into their families. Cognitive According to Jean Piaget 12 Cognitive development for Piaget is an orderly, sequential process in which a variety of new experiences must exist before intellectual abilities can develop. There are five major phases and April, based on her age, is supposed to be at the formal operations phase where rational thinking and deductive and futuristic reasoning is expected. However, her current condition does not enable the student nurse to assess fully her cognitive abilities at the absence of her psychosis. Moral Development According to Laurence Kohlberg There are three levels and six stages. April is at the conventional stage where the person is concerned with maintaining expectations and rules of the family, group, nation, or society. There is a sense of guilt that affects behavior. She is at the stage 3: Interpersonal Concordance Orientation where decisions and behavior are based on concerns about other’s reactions, the person wants others’ approval or a reward. April, based on her significant other’s account, was at this stage when her addiction developed and is still at the stage now. According to Carol Gilligan The student nurse has difficulty pinpointing at what specific stage the client is due to the limited time of contact with the client. Stage 3: 13 caring for self and others prevailed. The concept of responsibility now involves responsibility for self and others. Spiritual Development According to James Fowler James Fowler describes the development of faith as a force that gives meaning to a person’s life. Ideally, April is at the synthetic-conventional is structured by the expectations and judgment of other; interpersonal focus. According to Wersterhoff April is at the experience faith stage which is a stage not normally for young adult based on Westerhoff’s theory. At this stage, client experiences faith through interaction with others who are living particular faith tradition. 1.3.2 The ill person at particular stage of patient Developmental Task theory Based on the student nurse’s assessment on the client, April has failed to achieve the last 7 tasks, starting from achieving emotional independence from the parent and other adults. Even though April has gone emotionally distant from her parents, it is not a sign of being emotionally mature and independent. It is just another way diverting her emotional needs and conflicts because she couldn’t reach them. 14 There has been no assurance of economic independence all throughout her childhood and adolescent years because the family is struggling financially. Selecting and preparing for an occupation and married life wasn’t on her list of priorities for the past years because she got hooked with an illegal substance and all she could think of were means of supporting her vices. April stopped going to school at the age of 15 and didn’t go through any livelihood trainings or seminars so skills and concepts necessary for civic competence weren’t met either. A socially responsible behavior isn’t observable considering that what she had done and what she had gotten herself hooked to is a menace to the society and one of the major reasons why the crime rate is rapidly escalating. Values and ethical system are vague yet and self-awareness and value clarification are ought to be realized. Psychosocial development According to Sigmund Freud Based on the account of the client’s significant other, client was found out to be orally fixated. Her mother mentioned about difficulty providing her5 eldest daughter with the appropriate nutrition whenever she cries for feeding at times due to financial restraints. People who are orally fixated exhibit signs such as sucking thumb beyond toddlerhood, biting or always puting objects into her mouth such 15 as a pen or a pencil. This could be one of the factors involved in the client’s smoking vice.Client is now at Genital stage; however, her coping skills are underdeveloped. According to Erik Erickson Client was unsuccessful in her industry vs. inferiority task during her school age years. She has not developed a sense of competence and perseverance which lead to her withdrawal from school. Due to this failure, she has difficulty progressing through the adolescent central task of identity vs. role confusion. Client is making no effort to actualize her abilities.She is indecisive and has antisocial tendencies, like withdrawing from her significant others and getting involved in illegal activities. According Roger Gould Client has not matured enough and based on her actions, has not tried to assume a new adult role. Based on observation, client seemed to exhibit regression. During the whole student nurse-client interaction, client seemed to be anxious that she’ll get separated from her mother. Cognitive Development According to Jean Piaget Rational thinking and deductive and futuristic reasoning of the formal operations phse has not been observed by the student nurse from 16 the client. Priamary reason for this is the client’s current state: psychosis due to substance abuse, specifically cocaine. Due to this fact, the student nurse faces a great challenge on how to do health teaching effectively. Moral Development According to Laurence Kohlberg Conventional stage and Interpersonal concordance orientation basically speaks of societal pressure. Aside from being genetically predisposed, one of the factors that lead to the client’s condition was her peers. At 15, she got mixed up with a bad crowd and started using drugs due to peer pressure. “Gipasuway man ko nila,” as verbalized by the client when asked regarding the start of her vice. According Carol Gilligan There was a time when the student nurse touched the topic about the client’s siblings. Before that, the client answered the student nurse’s questions sensibly; however, when asked how were her siblings at home and whether she missed them or not, the client exhibited circumstantiality. She tried to avoid the topic. Her mother said that the client is deeply concerned when it comes to her siblings. During her stay in the ward, whenever she has extra food, she would tell her mother to save it for her siblings. These behaviors gave the student nurse clues as to the client’s 17 sense of responsibility. She’s concerned not only on her own welfare but also that of her siblings’. Spiritual The spiritual development has proved to be difficult to assess in a person like April who is suffering from a substance abuse psychosis and who refuses to answer when it comes to questions such as: do you think what you are into now is a punishment from God? Her mother stated that she goes to church and prays with the family whenever her mother makes an enough effort to encourage her. 18 2. Mental Status Exam A. Appearance Client was seen wearing a red shirt and maong pants, with a brown step-in sandals to match. She was not wearing any make-up. The only accessory she had on was a multi-colored bracelet in her left arm. Client is thwenty years old and looks her age. She has dry skin and on it are four genuine tattoos found on her left ring finger, another one on her forearm(dorsal part), on her scapular region which was shaped like a cross, and on her right lower extremity. B. Affect Client’s facial expression does not convey emotion most of the time, that was during the student nurse-client interaction. It remained constant all through out the conversation. C. Behavior, Attitude and Coping Patterns During the whole interaction, client did not exhibit any strange, threatening, and violent behavior. She just sat on a bench, cross-legged. No evidence of unusual mannerisms or motor activity. She has a normal gait and posture. Client appeared to be evasive as evidenced by her short statements and stands up whenever the student nurse sits beside her. During interviews, she seemed to prefer sitting beside her mother. 19 D. Communication and Social Skills Client spoke coherently and enunciated clearly. She responded only when questioned and spoke with a loud voice. Client did not exhibit neologism nor verbigeration; however, when asked about her family, she displayed circumstantiality, stating unnecessary details irrelevant to what was being asked. E. Content of Thought Client claimed to have not experienced any delusions nor any kind of hallucinations. No outward signs of compulsion and obsessions. F.Orientation During the two interactions that took place, client appeared to be personoriented, place-oriented and time-oriented. When asked, client could say her name in full. G.Memory When asked, client could recall certain fragments about her childhood and high school life.She was able to tell the student nurse what happened hours prior to her admission to the psychiatric ward. H. Intellectual Ability Client can use facts comprehensively. When asked if she can recall student nurse’s name, client discretely glanced at the student nurse’s name plate which 20 indicates that she can read.Client can do simple mathematical equations such as addition, subtraction, multiplication and division but has difficulty counting backwards. I. Insight Regarding Illness or Condition Client was in denial of her condition.”Dili ko praning kay wa ko gagamit,” as verbalized by the client referring to her state. J. Spirituality Client is a Roman Catholic. Does not respond when asked about her spiritual values. K. Sexuality Client haven’t express any concerns regarding sexual identity and function . According to her mother, she did not have any boyfriend since she was sixteen years old. When April was fourteen years old, she was admitted by her boyfriend at North General Hospital due to massive bleeding. She was diagnosed to have had uterine laceration. L. Neurovegetative Changes Client claimed to have no difficulty falling and staying asleep at night, despite their current condition. They currently sleep on a bench in the Psychiatric 21 ward common room. Client’s appetite has improved according to her mother. Her mother stated that the client seldom eats at home, especially when she’s “tama”. Client defecates regularly, according to her mother. 3. Psychopathology and Rationale 3.1 Normal Anatomy and Physiology of Organ and System Affected The Brain The adult brain’s unimpressive appearance gives few hints of its remarkable abilities. It is about two good fistfalls of pinkish gray tissue, wrinkled like a walnut, and with the texture of cold oatmeal. It weighs a little over three pounds. Because the brain is the largest and most complex mass of nervous tissue in the body, it is commonly discussed in terms of its four major regions- cerebral hemispheres, diencephalons, brain stem and cerebellum. Speech, memory. Logical and emotional response, as well as consciousness, interpretation of sensation and voluntary movement, are all functions of cerebral cortex neurons. The major structures of the diencephalon are the thalamus, which encloses the shallow third ventricle of the brain, the hypothalamus which is an 22 important part of the limbic system and the epithalamus which has the pineal gland and choroids plexus. Structures of the brain stem are the midbrain, wherein reflex centers for vision and hearing are found, the pons which is involved in the control of breathing and the medulla oblongata which regulate vital visceral activities. The Limbic System The limbic system sets the emotional tone of the mind, filters external events through internal states( emotional coloring), tags events as internally important, stores highly charged emotional memories, modulates motivation, controls appetite and sleep cycles, promotes bonding, directly processes the sense of smell, and modulates libido. The Blood-Brain barrier No other body organ is so absolutely dependent on a constant internal environment as is the brain. Other body tissues can withstand the rather small fluctuations in the concentrations of hormones, ions and nutrients that continually occur, particularly after eating or exercising. If the brain were exposed to such chemical changes, uncontrolled neural activity might resultremember that certain ions (Na and K) are involved in initiating nerve impulses, and some amino acids serve as neurotransmitters. Consequently, neurons are kept separated from blood borne substances by a so-called blood brain-barrier, composed of the least permeable capillaries in the whole 23 body.Of water soluble substances, only water, glucose and essential amino acids pass easilty throught he walls of these capillaries.The blood brain barrier is virtually useless against fats, respiratory gases and other fat-soluble molecules that diffuse easily through all plasma membranes.This explains why blood-borne alcohol, nicotine, cocaine and anesthetics can affect the brain. 3.2 Psychopathology A large number of toxic or psychoactive substances can cause psychotic reactions. Such substance-induced psychosis can occur in multiple ways. First, people may inadvertently ingest toxic substances by accident, either because they don’t know any better or by mistake. Alternatively, people may take too much of a legitimately prescribed medicine, medicines may interact in unforeseen ways or doctors may miscalculate the effects of medicines they prescribe. Finally, people may overdose on recreational drugs they commonly use ( such as cocaine), or become dependent on drugs or alcohol and experience psychotic symptoms while in withdrawal from those substances. This is basically what happened to April Michelle Tecson. Cocaine is a naturally occurring alkaloid found within the leaves of a shrub, Erythroxylon coca.. In the late 19th century, Sigmund Freud proposed cocaine for the treatment of depression, cachexia, and asthma. It later became prescribed for almost any illness and could be found in numerous tonics. In 1885, John Styth Pemberton registered a cocaine-containing drink in the United States. This drink was later named Coca-Cola. In 1914, the Harrison 24 Narcotics Act banned all nonprescription use of cocaine. Finally, in 1970, the Controlled Substances Act prohibited the possession of cocaine in the United States, except for limited medical uses. The Diagnostic and Statistical Manual of Mental Disorders notes that a diagnosis is made only when the psychotic symptoms are above and beyond what would be expected during intoxication or withdrawal and when psychotic symptoms are severe. The following are the criteria necessary for diagnosis:   cessation or reduction in previously heavy or prolonged cocaine use The patient also must have a dysphoric mood associated with 2 of the following 5 physiological changes: -Fatigue -Vivid unpleasant dreams -Insomnia or hypersomnia -Increased appetite -Psychomotor agitation or retardation  These signs or symptoms result in significant distress in the patient clinically and may impair the patient's social or occupational areas of functioning. The patient may experience significant depressed mood with suicidal ideation.  Mental status examination may show a sleepy, slowed-down patient who complains of depressed mood and has a restricted affect. They may express suicidal ideation. 25 Fig. 1 Schematic Diagram of Psychopathology of the illness Predisposing Factors Biological -genetics -brain damage From previous disease: meningitis  Psychological -unresolved self-conflicts -failed developmental tasks Environmental -deficiency of vitamin B complex -viral infection Spiritual -financial status -relationship with members of the community Precipitating Stressors  financial constraints  personal inadequacies  peer pressure Blockade of catecholamine reuptake occuring in both the central and peripheral nervous systems (ie, norepinephrine, dopamine, and serotonin reuptake blockade) Signs and Symptoms Delusions; flight of ideas; alogia;hallucination Medical Management -stabilize psychotic symptoms with medications Nursing Management -eliminate alcohol and substance abuse; monitor for suicidality and homicidality; decrease environmental stress; promote healthy relationship; encourage verbalization of problems and assist in art therapy and remotivation therapy 26 3.3 Disease Process and its Effect on the Different organ/system Phase1(crash) 9hrs.-4days Phase2(withdrawal) 1-10 weeks Cocaine Binge Early dysphoriadepression,anxiety and agitation Middle Fatigue Depression No cocainecraving Insomnia with increased need for sleep Late Exhaustion Hypersomnolence Hyperphagia No cocaine craving Early Sleep normalized Euthymic mood Low cocaine craving Low anxiety Middle&Late Anhedonia Anergia Anxiety High cocaine craving Conditioned cues exacerbate craving craving Phase3(extinction) indefinite Normal hedonic response Euthymic mood Episodic craving Conditioned cues triggering craving abstinence Fig. 2 Pattern of Cocaine Use 27 Cocaine has a number of pharmacologic effects on the human body. Neuronal fast sodium channel blockade produces a local anesthetic effect that continues to be used in medicine today. During myocardial fast sodium channel blockade, cocaine blocks fast cardiac sodium channels, which results in type I antidysrhythmic activity. This may lead to prolongation of the QRS complex and contribute to the induction of the dysrhythmias associated with cocaine use. Blockade of catecholamine reuptake (ie, norepinephrine, dopamine, and serotonin reuptake blockade) occurs in both the central and peripheral nervous systems. Blockade of reuptake of norepinephrine leads to the sympathomimetic syndrome associated with cocaine use. This syndrome consists of tachycardia, hypertension, tachypnea, mydriasis, diaphoresis, and agitation. Inhibition of dopamine reuptake in the CNS synapses, such as in the nucleus accumbens, contributes to the euphoria associated with cocaine. Norepinephrine release augments norepinephrine reuptake blockade effects. Cocaine abuse is associated with numerous detrimental health effects. All organ systems can be adversely affected by its use. Cocaine-related psychiatric disorders have been well-documented in the literature. Ten cocaine-induced psychiatric disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR).Some of them are cocaine withdrawal, cocaine-induced psychotic disorder with delusions and Cocaine-induced psychotic disorder with hallucinations. 28 3.4 Classical and Clinical Symptoms Classical Symptoms Clinical Symptoms Rationale Delusion, fixed but false beliefs -false sense of grandeur also called cocainomania Client did not exhibit delusions of grandeur An excess of dopamine affecting the cortical areas of the brain.This gives the client perceptions which are not based on reality Source:Psychiatric-Mental Health Ng. by Shives Flight of ideas When client talks she sometimes jumps from one topic to another.(refer to process recording no.5) An excess of dopamine which results in the firing of neurons with varied different and multiple impulses to the brain Source: Psychiatric-Mental Health Ng. by Shives Alogia, poverty of content Client often speaks very little or conveys little substance of meaning Organic functional changes in the brain and cerebral atrophy from imbalances in 29 neurotransmitter levels in the brain.This decreases the speed and how much information is processed in the brain. Source: Psychiatric-Mental Health Ng. by Shives Hallucinations, most commonly tactile and olfactory Client laughs by herself The excess of dopamine in the cortical areas of the brain gives the client perceptions which are not based on reality Source: Psychiatric-Mental Health Ng. by Shives Anhedonia (loss of pleasure or interest) Client rarely interacts with her siblings anymore and A negative symptom caused by an inadequate amount of does not engage in activities dopamine, cerebral atrophy that used to be fun for her .This is according to her mother. or organic functional changes that the client’s brain may have undergone. Source: Psychiatric-Mental 30 Health Ng. by Shives Client does not engage in Anergia( lack of energy) activities that used to be fun for her .This is according to her mother. A negative symptom caused by an inadequate amount of dopamine, cerebral atrophy or organic functional changes that the client’s brain may have undergone. Source: Psychiatric-Mental Health Ng. by Shives Client gets anxious Anxiety whenever her mother is not beside her. This is caused by an inadequate amount of dopamine, cerebral atrophy or organic functional changes that the client’s brain may have undergone. Source: Psychiatric-Mental Health Ng. by Shives High cocaine craving Not exhibited by the client. Inhibition of dopamine reuptake in the CNS synapses, such as in the 31 nucleus accumbens, contributes to the euphoria associated with cocaine which in turn triggers intense craving. Source: Davis, F.A. Taber’s Cyclopedic Medical Dictionary 32 IV. Nursing Intervention 1. Care Guide of Patient with Substance-induced Psychosis a. Treatment Settings Residential programs/ therapeutic communities may be helpful.A client typically spends six to twelve months in such programs, which may also include vocational training and other features. But of course, the client’s financial status and ability to cover treatment is also an issue that affects the patient’s access to treatment. Dr. Yazar have recommended that April be transferred to a drug rehabilitation center but April’s mom still has difficulty finding a rehabilitation center that they can afford. b. Psychotherapy Contingeny management rewards drug abstinence( confirmed by urine testing) with point or vouchers which patients can exchange for such things as an evening out or membership in a gym. Cognitive behavioral therapy help users learn to recognize and avoid situations most likely to lead to cocaine use and to develop healthier ways to cope with stressful situations most likely to lead to cocaine use and to develop healthier ways to cope with stressful situations. Clients in similar situation with April should also be assessed for risk of harm to self or to others. This also may mandate further inpatient care. Careful assessment for suicidal ideation, plans, and level of intent to act on 33 such ideation is crucial. If a plan and intent to act is present, psychiatric hospitalization is almost always warranted, even if requiring involuntary commitment. Also, assessing homicidal ideation, intent, and plan is critical. Not only may the patient require voluntary or involuntary psychiatric hospitalization, but one also may have a duty to warn an intended victim. Supportive therapy helps patients to modify their behavior by preventing relapse by taking actions such as staying away from drug-using friends and from neighborhoods or situations where cocaine is abundant. Behavioral therapies have been designed to prevent relapse in patients addicted to cocaine. These therapies help minimize exposure to drug cues and help modify patients' responses to cues they encounter. For example, a relapse prevention strategy may include minimizing the free cash the cocaine addict has available to buy drugs. Another example is behavioral therapy such as contingency management, in which vouchers are provided and are redeemable for goods or services contingent on performance of desired behaviors. c. Diet and Nutrition The student nurse should promote adequate fluid intake ( 2,5003000 cc/ day) and promote intake of fresh fruits, vegetables and bran products. These are precautionary measures to lessen the side effect of psychotropic drugs given . Constipation is a common side effect of the drugs given to April. 34 The use of low calories or sugarless hard candy, mints, gum or beverages is encouraged if the client experiences dry mouth as a side effect. Nausea and vomiting or irritation may present as a transient side effect so medication must be taken with food. With the help of the dietitian or nutritionist, April can be given a more holistic care. d. Medications There are numerous medications have been studied for the treatment of cocaine addiction, and many show promise. Topiramate, an anticonvulsant, shows some promise for cocaine-dependent patients. Baclofen and tiagabine, as well as modafinil have also shown promise in reducing cocaine use. Disulfiram may increase the aversive effects of cocaine and reduce its use. Other recent work has suggested that a cocaine vaccine may induce the formation of sufficient antibodies to reduce cocaine use. As of now, April has been given Haloperidol, Chlorpromazine and Biperiden. Haloperidol is an antipsychotic nonphenothiazine while chlorpromazine is also an anti-psychotic but that of the phenothiazine type. Biperiden, an antiparkinsonian, is given as a prevention of the extrapyramidal side effects that accompany phenothiazine therapy. 35 2. Actual Patient Care: 2.1 Nursing Care Plan Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Hospital No. 6184112 Ward No. XII Date: 09/17/07 Physician: Dr. Yazar Nursing Care Plan Needs/Problem Cues I. Psychologic deficit: Nursing Diagnosis Goal: After 2 weeks of student A. Impaired verbal communication Impaired verbal communicat ion: Cues: incomprehe Cocaine produces pleasurable effects through its action on nurse-client interaction, the client will be able to establish trust, gain 1. attempt to decode incomprehensible communication patterns 1.reveal how the client is being perceived by others while the responsibility of I. improve the quality of verbal communication Scientific Basis Objectives of Care Nursing Actions Rationale Measures to: 36 nsible -client’s statements are often incomprehensi ble - client is silent most of the time but when talked to, responds in a loud voice -client usually responds in short statements related to looseness of association structures deep within the brain-most notably, a region called the ventral segmental area. A cocaine binge (repeated use with increase amount) may rapport, gain insight of reason of admission and show adaptive attitude towards stressful situations 2. seek validation and clarification on ambiguous statements understanding the client is accepted by the student nurse pg.285-286; Psych.Ng. by Townsend 2.prevents making assumptions and genuinely attempts to understand client-pg.285-286; Specific Objectives: 3.facilitate trust and understanding by maintaining staff assignments as possible Psych.Ng. by Townsend cause increasing After 30-45 irritability, restlessness and paranoia; min. of student nurse-client interaction, the 3.This approach conveys empathy and may encourage client to disclose painful issues-pg.285-286; 37 statements and sometimes does not respond at all -“Tan-aw nila ug praning na ko,” as verbalized by the client possible resultant fullblown paranoid psychosis, loss of touch of reality and auditory hallucinations. Pg. 293, Straight A’s in Psychiatric Mental Health Nursing; Lippincott client will be able to: 4. anticipate and care for 1.express herself effectively , as efvidenced by an interaction wherein her responses can be understood by the student nurse 5. orient client to reality by name and validate those aspects of communication that help differentiate between what is real and what’s not client’s needs until functional communication pattern returns Psych.Ng. by Townsend 4.Client’s safety and comfort are nursing priorities-pg.285-286; Psych.Ng. by Townsend 5. These facilitate restoration of functional communication patterns of client-pg.285-286; Psych.Ng. by Townsend 38 Williams & Wilkins B. Impaired social interaction Impaired social interaction: difficulty Cues: -client has difficulty maintaining eye contact -client has a “glazed look” -client answers curtly in short maintaining eye contact related to client’s withdrawal The deep limbic 2. effectively II. promote social interaction system/structure communicate s are also intimately involved with bonding and social connectedness. When the deep with the student nurse as evidenced by maintenance of eye contact and improved responses to student nurse’s questions 1. encourage client to verbalize problems and perceptions of reasons of problems 1.actively listen to note indications of hopeless ness, powerlessness, anxiety, grief and hatepg.481,Nursing Care Plan by Doenges from society limbic system is damaged due to several factors such as trauma 2. determine the use of coping skills and defense mechanisms 2. It affects the ability to be involved in social interactions-pg. 483, 39 statements most of the time -“Excuse sa te ha,” as verbalized by the client and chemical hzzards, the ability to connect with other people on a social level is affected. 3. encourage client to keep a daily journal of social interactions Nursing Care Plan by Doenges 3. to keep a baseline data for changes/; improvements or exacerbations- pg. 483, Nursing Care Plan by -pg. 1953-1956; Taber’s Encyclopedic Medical Dictionary by F.A. Davis Doenges 4. assist the client to develop 4. to slowly reorient client positive social skills through practice of skills in real social situations accompanied by a support to the reality of social interaction- pg. 483, Nursing Care Plan by Doenges 40 person, and 5. encourage reading, listening to news and remotivation therapy 5. to reorient the client to reality while not yet fully exposing her to full social interaction- pg. 483, Nursing Plan;Doenges II. Psychologic overload: Impaired thought processes: A cocaine binge may cause increasingly irritability, restlessness and paranoia; possible 3. exhibit a coherent train of thoughts, as evidenced by the client sharing one past experience and III. decrease erratic thinking processes: 1. reorient the client to the time, place and day 1. to promote reality based interaction-pg.531, Nurse’s Pocket Guide; Doenges A. Impaired thought processes inappropriat e answers to questions related to 2. schedule structured activities and rest periods 2.to provide stimulation 41 Cues: - inappropriate answers to questions -usually responds in short statements -do not respond directly circumstanti ality resultant fullblown paranoid psychosis, loss of touch of reality and auditory hallucinations. –pg.293, Straight A’s in Psychiatric Nursing; Lippincott Williams can be understood by the student nurse. 3. give simple questions without undue fatiguepg.531, Nurse’s Pocket Guide; Doenges 3. to clarify and simplify activities for the client-pg. 532, Nurse’s Pocket Guide; Doenges 4. ask leading questions 4. to refocus conversation in one topic-pg. 532, Nurse’s Pocket Guide; Doenges 5. clarify and refocus if client exhibits circumstantialit 5. to refocus conversation in one topic-pg. 532, Nurse’s Pocket Guide; 42 2.2 Brunswick Lens Model Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Hospital No. 6184112 Ward No. XII Date: 09/17/07 Physician: Dr. Yazar Measures to: I. Psychologic deficit: A. Impaired verbal communication -statements are often incomprehensible - silent most of the time -client usually responds in short statements -“Tan-aw nila ug praning na ko,” as verbalized by the client B. Impaired social interaction -client has difficulty maintaining eye contact -client has a “glazed look” -client answers curtly in short statements most of the time -“Excuse sa te ha,” as verbalized by the client II. Psychologic overload: A. Impaired thought processes - inappropriate answers to questions -usually responds in short statements -do not respond directly Actual state Of patient’s condition Cues I. improve the quality of verbal communication - attempted to decode incomprehensible communication patterns - sought validation and clarification on ambiguous statements -facilitated trust and understanding by maintaining staff assignments as possible - anticipated and care for client’s needs until functional communication pattern returns -oriented client to reality by name and validate those aspects of communication that help differentiate between what is real and what’s not II. promote social interaction - encouraged client to verbalize problems and perceptions of reasons of problems - determined the use of coping skills and defense mechanisms - encouraged client to keep a daily journal of social interactions -assisted the client to develop positive social skills through practice I. Impaired verbal of skills in real social situations accompanied by a support person, communication: and incomprehensible statements -encouraged reading, listening to news and remotivation therapy related to looseness of II. Impaired social interaction: difficulty III. decrease erratic thinking processes: association maintaining eye contact related to -reoriented the client to the time, place and day client’s withdrawal from society -scheduled structured activities and rest periods -gave simple questions III Impaired thought processes: - asked leading questions inappropriate answers to questions - clarified and refocus if client exhibits circumstantiality related to circumstantiality Nursing Diagnoses Nursing Actions Desired Outcome Goal:After 2 weeks of student nurse-client interaction, the client will be able to establish trust, gain rapport, gain insight of reason of admission and show adaptive attitude towards stressful situations Specific Objectives: After 30-45 min. of student nurse-client interaction, the client will be able to: 1.express herself effectively , as evidenced by an interaction wherein her responses can be understood by the student nurse 43 2.3 Drug Therapeutic Record Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Drug Therapeutic Record Drug/Route/Do sage/ Timing Classification/ Mechanism of action Indication/Contrain dication/ Adverse effects Principles of Care Treatment Evaluation Haloperidol, PO, 20mg, ½ tab, OD 8am Typical antipsychotic ; nonphenothia zine I:  management of  do not allow  encour manifestations of psychotic disorders client to crush or chew medication to prevent decrease in age client to join in therapies  orient Client’s blood pressure was taken before she was given the medication. “Muinom ra pud biya siya. Dili ra pugsunon”, as verbalized by the client’s significant other. MOA: Mechanism not fully understood. Provides a symptomatic control for the client by blocking the activity of  control of tics in Tourette’s syndrome  behavioral problems in children with combative, explosive;hype rexcitability;sh ort-term absorption and client to effectiveness reality  advise client by not to avoid being in direct encourag ing sunlight for an distorted extended time  good oral perceptio ns of 44 dopamine, which has the potential to produce psychotic thinking. Too much dopamine causes nerve impulses in the brain stem to be transmitted faster than normal, resulting in strange thoughts and  treatment for children with excessive motor activity, mood lability C/I: hypersensitivity Parkinson’s hygiene should be encouraged to avoid mouth infections  assist in CBC monitoring  monitor for reality  encour age complian ce of taking medicati ons on time disease liver damage early signs of  discour extrapyramida age use l side effects of alcohol and other additive drugs A/E:  anticholinergic effects: dry mouth,drowsines s, nasal congestion, constipation  dermatitis hallucinations photosensitivity . Also has anti-emetic property. GI distress weight gain extrapyramidal side effects 45 source: pg. 235, PsychiatricMental Health Ng. by Shives 46 Drug/Route/Do sage/ Timing Classification/ Mechanism of action Indication/Contrain dication/ Adverse effects Principles of Care Treatment Evaluation Chlorpromaz ine hydrochlorid e,PO, 100mg, I tab, OD at hour of sleep Typical , antipsychotic, phenothiazine I:  management of  do not allow  encour manifestations of psychotic client to crush or chew medication to prevent decrease in age client to join in therapies  orient Client’s blood pressure was taken before she was given the medication. “Muinom ra pud biya siya. Dili ra pugsunon”, as verbalized by the client’s significant other. MOA: Not fully understood. Blocks postsynaptic dopamine receptors in the brain. Depresses those parts of the brain disorders  relief of preoperative restlessness; control of manicdepressive illness  adjunct treatment of tetanus absorption and client to effectiveness reality  advise client by not to avoid being in direct encourag ing sunlight for an distorted extended time  good oral hygiene should be encouraged to avoid mouth infections perceptio ns of reality  encour age complian ce of involved with  therapy for wakefulness and emesis; combativeness, hyperactivity anticholinergi  control of c, nausea and 47 antihistaminic and alphaadrenergic blocking vomiting C/I: hypersensitivity Parkinson’s  assist in CBC monitoring  monitor for taking medicati ons on time disease source: pg. 235, PsychiatricComa Bone marrow early signs of  discour extrapyramida age use l side effects of alcohol and other additive drugs depression Mental Health A/E: Ng. by Shives  anticholinergic effects  dermatitis photosensitivity GI distress extrapyramidal side effects 48 Drug/Rout e/Dosage/ Timing Classification/ Mechanism of action Indication/Contrain dication/ Adverse effects Principles of Care Treatment Evaluation Biperiden hydrochl oride, PO, 2mg, 1 tab, OD Antiparkinsonian I:  adjunct therapy  drug  encourag e client to take antipsycho tic medication s exactly as prescribed  do health teaching to Client’s blood pressure was taken before she was given the medicatio n. “Muinom ra pud biya siya. Dili ra pugsunon” , as verbalized by the client’s significant MOA: Blocks the action of acetylcholine in the brain and peripheral nervous system in attempt to correct an imbalance between a deficiency of dopamine and abundance of acetylcholine. of parkinsonism  relief of extrapyramidal side effects that accompany phenothiazine therapy C/I: hypersensitivity glaucoma myasthenia should be tapered gradually to prevent withdrawl symptoms  advise client to avoid the use of alcohol,sedat the client’s ive and over the counter drugs  advise against staying long under the significant other regarding the early signs of extra pyramidal gravis prostatic hypertrophy A/E: source: pg. 235, PsychiatricMental Health  psychosis  depression hallucinations 49 Ng. by Shives insomnia irritability sun side effects  encourage complianc e of taking medication on time other. 50 2.4 Health Teaching Plan Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Health Teaching Plan Objectives General: Within 2 weeks of student nurse-client interaction, the client wil be able to acquire adequate knowledge, attitude and skills regarding the use of coping skills whnever the need arises. Specific: Within 45 min. of student nurse-client interaction, the client will be able Content Methodology Evaluation 51 to: 1. state the importance of using coping mechanism 1.Importance of using a coping mechanism -reduces stress and lightens up your mood -reduces anxiety -enables a person to still function in work despite current crisis 2. identify health hazards of not being able to use coping 2. Hazards of not being able to use proper coping Informal discussion Informal discussion Client was barely listening. She easily gets distracted by the events around her. However, at the end of the health teaching she stated the that she prefers writing on a journal as a means of coping. mechanisms dcuring mechanisms stressful situations -person would turn to vices like smoking, drinking, drugs -aggravates mental illness Informal discussion 52 3. enumerated coping mechanisms available 3. enumerate coping mechanisms available -talking to a bestfriend or significant other about problems -putting troubling thoughts in a journal Informal discussion -drawing -listening to music -playing sports -joining in yoga and other relaxation classes 4. choose a coping mechanism she is comfortable with 5. verbalize willingness to try to use the coping mechanism 4. choose a coping mechanism she is comfortable with 5. client’s verbalization of willingness to use the coping mechanism Informal discussion “Gahanan ko magsuwat.,” as verbalized by the client.. Client stated that she preferred writing on a journal as a means of coping. 53 2.5 SOAPIE and Process Recording Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar SOAPIE No.2 S- “Maayong buntag,” as verbalized by the client O- client is still silent most of the time but responds with a loud voice when talk to, usually responds in short statements and when asked about her siblings, she does not respond correctly; instead, exhibits circumstantiality A-Impaired thought processes: inappropriate answers to questions related to circumstantiality P- to decrease erratic thinking process I- reoriented the client to the time, place and day; scheduled structured activities and rest periods; gave simple questions; asked leading questions; clarified and refocused if client exhibits circumstantiality E- client was still not ready to openly discuss her troubled past Student nurse: Casinillo, Rhia Marie B. 54 Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar SOAPIE No.3 S- “Excuse sa te ha,” as verbalized by the client O-client has difficulty maintaining eye contact; client has a “glazed look”; client answers curtly in short statements most of the time A- Impaired social interaction: difficulty maintaining eye contact related to client’s withdrawal from society PI- to promote social interaction . encouraged client to verbalize problems and perceptions of reasons of problems; determined the use of coping skills and defense mechanisms; encouraged client to keep a daily journal of social interactions; assisted the client to develop positive social skills through practice of skills in real social situations accompanied by a support person, and encouraged reading, listening to news and remotivation therapy E- client still answered in short statements but was able to stay with the student nurse for approximately 5 minutes without the presence of her mother Student nurse: Casinillo, Rhia Marie B. 55 Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Process Recording No. 1 I. Objectives a. General Objective: After 2 weeks of student nurse-client interaction, the client will be able to establish trust, gain rapport, gain insight of reason of admission and show adaptive attitude towards stressful situations. b. Specific Objectives: After 30-45 min. of student nurse-client interaction, the client will be able to: 1. establish trust on the student nurse-client interaction, the client will be able to: maintaining eye contact during interaction asking questions 2. abide by the “lagda” or contract set by the student nurse and agency 3. show essential details that lead to client admission 4. verbalize feelings and concerns as regarding present situation 5. agree to date, time and place of the next interaction 56 II. Setting a. Date: September11, 2007 b. Time: 11:00 am to 11:30 am c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common room III. Appearance The client was seen sitting on a bench in the common room. She was wearing a relatively clean black shirt and pink pants. He rhair was neatly combed. Her belongings were packed in a bag. She was well taken care of by her mother who was with her since her admission to the center, which was last September 8, 2007. IV. Behavior The client was cooperative; communicates but in short statements only. She maintains eye contact when talked to. She was silent most of the time. She does not mingle with other patients and preferred sitting with her mother. V. Communication The client did not exhibit neologisms, nor of pressured speech but exhibit flight of ideas, jumping from topics unrelated to the current topic of discussion and inability to concentrate. Client communicates in a loud voice. 57 VI. Interaction Student nurse’s Client’s verbal/ Communication verbal/ nonverbal communication non-verbal communication technique used Client’s Defense Mechanism Analysis “Maayong buntag A.T.” Client nods and stares at the student nurse Giving recognition -none used- The nurse calls the client by name to boost the client’s selfesteem and promote reorientation to her identity. “Ako diay si Rhia, imong student nurse na gikan sa Cebu Doctors’ University” “Estudyante sa Cebu Doc?” Giving information -none used- This action helps facilitate trust and build rapport by giving information about self or one’s self to the 58 client. “Makahatag ka sa eksaktong adlaw, petsa ug oras? Ug kung asa ta?” “Gidala ko nila Papa kay praning daw ko. Gidala ko dire sa Sotto atong Sabado” Client pauses and stares at student nurse. Asking direct question -none used- The nurse asks a question by interaction, to assess the client’s orientation. “Murag Martes ta karon” “Sakto na Martes ta karun. Setyembre 11, 2007.Makahatag ka sa eksaktong oras karon?” “Dili wala koy orasan” Exploring -none used- The nurse delves deeper to further assess the client’s orientation to reality and ensure that client is not just 59 guessing. Nurse provides “Alas onsi kapin Client nods ta karun sa buntag.” Giving information -none usedinformation to orient client to reality. The nurse asks “Kumusta man ang imo pamati karun?” “Ganahan na ko muoli.” Asking direct open endedquestion -none usedan open ended question to facilitate expression of feelings through continued communication. “Unsa man ang rason na nakaingon ka ana?” Client lies down on her mother’s lap. No answer. Exploring -regression- Nurse delves deeper to get further information. 60 VII. Evaluation Client was not very cooperative and appeared to be uncomfortable when the student nurse talked to her and asked her questions. She exhibited regression when she felt uncomfortable. Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Process Recording No. 2 I. Specific Objectives: 61 After 30-45 min. of student nurse-client interaction, the client will be able to: 1. recall the name of the student nurse 2. state the present date, time and place of the current interaction 3.verbalize feelings about the client’s present condition 4. identify the reason for current hospitalization 5. set the date, time and place of the next interaction II. Setting a. Date: September 12, 2007 b. Time: 10:45 am to 11:15 am c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common room III. Appearance The client was seen sitting on a bench in the common room. She was wearing a red shirt with maong pants. The client was able to perform activities of daily living, as evidenced by a neat and tidy appearance.. IV. Behavior The client was constantly glancing outside the window. She was always standing up to check the activities going on outside. Client can maintain eye contact for quite sometime but her eyes wander off constantly when asked about her family. 62 V. Communication The client did not exhibit neologisms, nor of pressured speech but exhibit circumstantiality, giving much unnecessary details that delay meeting a goal or stating a point. VI. Interaction Student nurse’s verbal/ nonverbal communication Client’s verbal/ Communication non-verbal communication technique used Client’s Defense Mechanism Analysis “Maayong buntag A.T.” “Maayong buntag” Client nods Giving recognition -none used- The nurse calls the client by name to boost the client’s self-esteem and promotes reorientation to her identity. 63 “Nakahinumdum Client looks at pa ka sa akong pangan?” student nurse’s name plate Asking direct question -none used- The nurse asks a question by interaction, to assess the client’s memory and orientation “Unsa man tang adlawa kaun A.T. ug unsang orasa na?” “Karun kay Setyembre 12, 2007. Alas 10:50 sa buntag” “Nakalimot ko.Alas dose na” Asking direct question -none used- The nurse asked a question by interaction, to “Okay” Giving information -none used- assess the client’s memory and orientation. “Kumusta man ang imong buntag?” “Okay ra man.Gikan unta ko sa gawas pero nisud ko Asking open ended question -none used- The nurse provided information to orient the 64 kay nay gaaway” client to reality. “Nisud ka kay nahadlok ka sa gaaway?” Client nods Restating -none used- The nurse asked an open ended question to start a conversation. “Nya unsa man “Wala” Client Asking direct open endedquestion -none used- The nurse restated the client’s statement for clarification. ang imo ganahan asked her buhaton karun?” mother to put oil on her back. “Sakit ba ang imong likod kaun?” “Oo” Client closes her eyes. “Panuhot” Seeking information -none used- The nurse asked an open ended question to continue conversation. 65 “Ganahan jud diay ka na ang imong mama maghilot nimo, sah?” Client’s mother answered for her: “Sukad pa atong bata neh siya day ganahan na jud neh siya hiluton nako. Lahi sa iyang mga igsoon” Client closes her eyes. Asking direct question -none usedNurse asked w the client is feeling, preventing formulation of assumption.. “Kinsa man ang gabantay sa imong mga igsoon karun?” Client stares at a distant object. Kagwapa nimo uy…ganahan jud ko nimo” Seeking information Negative attitude: Client gave much Circumstantiality unnecessary detail stating a point or to divert Student nurse’s attention from the 66 unwanted topic. “Murag galibog ko sa imong tubag sa akong pangutana.Unsa man ang imong pasabot?” Client does not look at the SN.She watches television instead. Seeking clarification Avoidance The student nurse asked a question to clarify the client’s reply. “Ganahan na ka mopahuway AT? Mubalik lang ko ugma ha sa pareho gihapong oras.Naa ra ka dire gihapon?” Client looks at the student nurse. O, sige. “Naa ra ko dire.” Giving information -none used- Student nurse and client agreed reading the next meeting time and place. VII. Evaluation Client was cooperative, answers questions but seemed distracted. She was awake, alert and oriented, with no impairments in mobility. She did not seem to want to talk 67 about her family, as evidenced by the circumstantiality she exhibited at the last part of the conversation. Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Process Recording No. 3 I. Specific Objectives: After 30-45 min. of student nurse-client interaction, the client will be able to: 1. recognize the student nurse 2. state the present date, time and place of the current interaction 3.respond to the student nurse’s questions appropriately 4. maintain eye contact for at least 3 seconds, and 5. agree with the student nurse regarding the date, time and place of the next interaction 68 II. Setting a. Date: September 13, 2007 b. Time: 10:30 am to 11:00 am c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common room III. Appearance The client was seen walking away from the area of the culminating activity carrying with her a cellophane with food. Shea was walking towards her mother. Client was wearing a brown halter top and pyjama pants. Her hair was neatly combed, and she was clean from her bath.She has already brushed her teeth and attended to her personal needs. IV. Behavior The client was uncommunicative at first. Every time the student nurse tries to sit beside her and start a conversation, she tries to excuse herself and walks toward her mother. She became cooperative after a few minutes, after she was done eating her burger and fries. She answered the student nurse’s questions. She did not exhibit any violent behavior. She participated in the student nurse’s drawing therapy.. V. Communication 69 The client spoke in short, curt statement.She had no echolalias nor palilalias.She exhibited looseness of association as evidenced by inappropriate answers to student nurse’s questions. VI. Interaction Student nurse’s verbal/ non-verbal communication Client’s verbal/ non-verbal communication Communication technique used Client’s Defense Mechanism Analysis “Maayong buntag A.T.” Client nods Giving recognition -none used- The nurse calls the client by name to boost the client’s selfesteem and shows that the client is recognized as an individual. The nurse asks “AT, Kahibaw “Alas diyes. Asking direct -none useda question by 70 kung unsa ang adlaw,petsa, ug kung aha ta karun?” Naa ko sa gawas kay gaculminating.” question interaction, to assess the client’s memory and orientation To boost the client’s “Sakto na alas diyes ta karun.Alas diyes kwarentay singko, Huwebes, Setyembre 13, 2007. Naa ta karun sa ground sa Vicente Sotto Memorial Health Center Psychiatry Ward” The nurse asks for descriptions Encouraging Client nods Acknowledgement -none used- confidence and reorient her to reality. and Asking direct question 71 “Kumusta man culminating activity ninyo AT?” No eye contact. “Okay ra man” Client stand up. Excuse sa ha. Client wals toward her mother. description Negative attitude: Avoidance to verify if client is oriented or aware to what’s going on around her.. The student nurse led the 10 minutes later…same setting client towards a therapeutic “AT, magdrawing ta nah” “Sige” Offering general leads -none used- activity. This assessed the client’s orientation and memory. “Unsa diay imong paborito na color AT?” Client reaches out for the green crayon. “Green” Asking direct question -none usedGiving recognition 72 After about 5 minutes boosts the client’s Client smiles and continues Giving recognition The student nurse delved deeper to learn more about the “Amo ning bay” Exploring and -none usedclient and what is possibly occupying her thought as of the moment. -none usedconfidence. “Nindot lageh na imong gidrawing AT?” drawing.. “Unsa man neh AT?” Student nurse points at the drawing of the client. “Sturyai ko unsa bahin ang imo gidrawing” Client points at her drawing. “Naa man to’y kahoy dapit sa bay. Nya sa sud kan-anan. Diri sa kilid kay bay sa silingan.” encouraging description “Wala man koy “Ah dinhi tapad sa bay gapuyo si Ilang, kato bestfriend” Asking direct question -none used- This assessed client’s memory. 73 imong bestfriend?” “Kanang bestfriend dib a mao na ang taw na masultian nimo sa imong problema?Di ba si Ilang man to imong masultian sa imong mga problema sauna?” Silence. “Wala man koy bestfriend” Reflecting -suppression/ Giving the repression Hard to identify which of the two was used client time to reflect on her previous statement.. “So wala kay bestfriend karun?Kinsa man ang imo masultian sa “Wala” Restating and asking a direct question. -None used- Student nurse restated client’s statement to encourage continued 74 imong mga problema? communication and possible sharing of feelings. “Kung naa kay problema dapat nimo ipagawas arun dili magsakit ang imong dughan AT. Mapagawas man na nimo paagi sa pagsuwat sa diary ug pwede pud magdrawing ka.” Giving information Client stares at the drawing. Giving information -none usedStudent nurse gave the client information about the different ways of coping whenever a crisis occurs and no one is available for her to turn to. Client has no response but shows receptiveness to teachings. “Okay ran neh?”Client show the 75 student nurse her drawing “O, nindot kayo AT.Salamat sa pagsturya nimo nako bahin aneng drawing ha. Mas nindot siya pag-explain nimo kay nasabtan nako.” Client looks at the student nurse and smiles. “Salamat pud” Giving acknowledgement Enhances the client’s self confidence and encourages continued communication. “AT, ugma ha magsturya na pud ta. Sa pareho gihapon na oras ug lugar, pwede didto sa taas o dire sa gawas.” “O, sige” Client smiles and nods at the student nurse. “Ugma nasad” Giving information -none used- Giving the client information to make her aware and wellinformed of the next activity. “Salamat AT. Apil diay pud “Muapil sad ko ana” Giving information -none used- This encourages 76 ug news therapy ugma ha. Mga alas 10:30 ta sa taas.” participation and awareness of the upcoming activity. VII. Evaluation The student nurse-client interaction was more productive this time because client was more cooperative and less avoidant compared with the previous conversations. Student nurse was able to get through the barrier of communication (e.g. in her case, the client’s significant other ; because student nurse has difficulty communicating with the client whenever the significant other is around because client expects the significant other to answer for her). Client was able to interact well with the individualized art therapy. Her train of thought was coherent and intelligible. 77 Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Process Recording No. 4 I. Specific Objectives: After 30-45 min. of student nurse-client interaction, the client will be able to: 1. recognize the student nurse 2. state the present date, time and place of the current interaction 3. respond to the student nurse’s questions appropriately as to 3.1 content of client’s auditory hallucinations 4. participate in the news therapy, and 5. agree with the student nurse regarding the date, time and place of the next interaction II. Setting a. Date: September 14, 2007 b. Time: 10:30 am to 11:00 am 78 c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common room III. Appearance The client was seen sitting at a bench in the OPD with her mother.She was scheduled for a n interview with Dr. Yazar. Client was well-groomed, wearing a clean brown shirt with a clean maong pants. Howver, her hair wasn’t properly kempt, as if she just arouse from bed. She has already taken a bath according to her significant other and has already done her activities of daily living like brushing her teeth. IV. Behavior The client was much more cooperative compared with the previous interactions. She exhibited signs of nervousness as evidenced by her frequent glancing at the stairs and at the physician’s clinic door. V. Communication The client answered the student nurse’s questions regarding the content of her auditory hallucination. Apart form, date and time disorientation, client was coherent all throughout the interaction and was able to answer appropriately. VI. Interaction Student nurse’s verbal/ Client’s verbal/ Communication non-verbal technique used Client’s Defense Analysis 79 non-verbal communication communication Mechanism “Maayong buntag A.T. Murag lipay lageh ka karun. Gaunsa man ka dinhi?” Client smiles “Interviewhon ko ni doctor para makauli na ko” Giving recognition -none used- The nurse calls the client by name to boost the client’s self-esteem and shows that the client is recognized as an individual. Assess the “Nakulbaan ka para sa interview?” Looks at the student nurse. “Okay ra man ko.Wa ra ko nakulbaan” Looks at the stairs and then the office door. Asking direct question -denialclient’s orientation to reality and current emotional status. 80 “makasulti ka kung unsa tan a adlaw, oras ug kung asa ta karun AT?” Looks at the stairs. “Dominggo man ta karun. Alas diyes. Padung ko maginterview” Asking direct question -none usedAssessed the client’s orientation to reality. “Biyernes ta karun AT.Alas diyes sa buntag, Setyembre 14, 2007. Naa ta karun sa OPD para sa imong interview kang Dr. Yazar” Client nods “Sakto. Sakto” Giving information -none used- Giving information to orient the client to reality. “O, naa na imong Doctor AT. Mao ban a siya si Dr. Yazar?” Client nods "O, ,mao na siya.Excuse sa ha.” Asking direct question -none usedAssessed the client’s orientation to reality. 81 VII. Evaluation The student nurse-client interaction was brief but productive. Client was cooperative and less avoidant. Student nurse was able to get through the barrier of communication, which in this case, was her mother because the client does not usually talk to the student nurse whenever her mother isn’t by her side. Name of Client: April Mechelle Tecson Diagnosis: Substance-induced psychosis Age: 20 years old Sex: Female Date: 09/17/07 Ward No. XII Physician: Dr. Yazar Process Recording No. 5 I. Specific Objectives: After 30-45 min. of student nurse-client interaction, the client will be able to: 1. recognize the student nurse 82 2. state the present date, time and place of the current interaction 3.recall the past experience with the student nurse for the past week 4. improve social interaction by joining the culminating activity 5. terminate the therapeutic student nurse-client interaction II. Setting a. Date: September 17, 2007 b. Time: 8:30 am to 9:00 am c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common room III. Appearance The client was seen sitting on a bench in the common room with her mother.She was talking to her mother about her food and at the same time she was getting ready fo the morning stretch. She had already taken a bath according to her mother. However, her hair wasn’t properly kempt probably due to her frequent scratching of her head. Client was wearing a white shirt and pyjamas. IV. Behavior The client was cooperative but exhibited irritability at some points of the interaction. She was much more talkative during this interaction compared with the previous ones. In 83 fact, she was the one who initiated the conversation when the student nurse arrived at the common room. She got irritated when she was asked the second time regarding the current date and place. V. Communication The client was much more talkative this time and was observed to have exhibited flight of ideas. She often does not state her ideas coherently, making it difficult for the student nurse to understand her statement. She easily gets distracted with ativities around her as evidenced by her frequent standing up and glancing outside while the conversation between the student nurse and client was going on. VI. Interaction Student nurse’s verbal/ non-verbal communicatio n Client’s verbal/ non-verbal communication Communicatio n technique used Client’s Defense Mechanism Analysis Client smiles at student nurse. “Hi ate” -none used- 84 Student nurse smile at AT. “Hi A.T.” Giving recognition The nurse calls the client by name to boost the client’s selfesteem and shows that the client is recognized as an individual. “Kumusta man ka karun?” “Okay ra. Muapil ko ug exercise.Mubalik lang ko inig human na.Excuse sa ha.” Asking direct question -none used- The nurse asks a question by interaction, to assess the client’s orientation to About 15 minutes later… reality. “Kumusta man ang morning Client smiles and wipes sweat off Asking direct question -none used- Assesed if client is 85 stretch?” her forehead. “Hangak ug kapoy uy.” aware of what is going on around her. “Naa pay music therapy taodtaod, gusto ka muapil AT?” “Di lang. mutanaw ra ko” Asking direct question -none used- The nurse provided information to orient the client to reality and give the client a choice as a sign of respecting her dignity. “Ah sige.AT, makaingon ka kung unsa tan a oras , petssa ug adlaw karun?” Client smiles “Alas nuwebe na daw ta. Muag lunes ta karun, diba?” Asking direct question -none used- Assessed if client is oriented to time and date. 86 “O sakto ka na alas nuwebe ta karun.”Lunes ta. Pero kahibaw ka unsa na na petsa?” Client’s face Giving -none used- The nurse provided information to orient the client to reality. turned serious and information her smile faded. “Setyembre 17, 2007. Maminaws na ta ha!” “O sige maminaw na ta” After about 5 minutes “Ate naa kay suwaton? Pwede ako musuwat?Ganaha n man gud ko magsuwat-suwat.” none -none usednone “Wala pero naa koy papel ug crayon dire.Suwat- mother. 87 suwat lang, tagaan tika.” After about 5 minutes “Nindot ug agi nimo AT.Mahilig diay ka magsuwat?” “O, mao neh akong buhaton sa bay” Client is busy writing “Sakto neh siya ate? Pailisdan nako akong Tshirt unya ha” Giving recognition Negative communication Giving recognition boosts the client’s selfesteem. : Flight of ideas “Unya na na huna hunaa AT. Mag focus sa ta karun sa ato topic bahin pagsuwat suwat” Client nods. “Sakto.sakto”. Refocusing -none used- The student nurse reoriented the client to the present topic of conversation and shifted her attention 88 to what is presently After about 5 minutes discussed. “AT naka dumdum pa ka sa akong gitudlo nimo ato niaging adlaw? Kato bahin sa mga buhaton nimo kung naa kay problema?” “O kanang mag suwat o magdrawing? Mas ganahan ko mag suwat Te kaysa sa magdrawing” Asking direct question -none used- This was to assess if the client was able to retain knowledge regarding coping mechanisms taught by the student nurse. “Maayo kay nakadumdum pa ka” Client nods and smiles. Giving recognition -none used- This boosts the client’s self confidence. “Ugma diay AT kay magsturya Client nods. “O sige te.Timan-an Giving information -None used- T o make the client aware 89 gihapon ta ha, sa pareho gihapong lugar. Timan-I tong akong gipangtudlo nimo ha” nako tanan” of the upcoming activity and inable her to act appropriately . “Last day na diay na mo ug ma AT. Hinaot unta na nakatabang ra ko nimo. Apil ta ug culmination karong Friday ha?” Client looks at the student nurse. "Dina ka mubalik te?” Giving information -none used- T o make the client aware of the upcoming activity and inable her to act appropriately “Di na mi mubalik sunod semana. Lahi na pud ang student Client smiles back. “Bye te” Giving information And expressing appreciation -none used- Giving information facilitates improve trust 90 nurse na makig amiga nimo. Salamat sa tanan AT” Student nurse smiles at the client. and expressing appreciation shows that client is being recognized as a person. VII. Evaluation The student nurse-client interaction was productive because client was more cooperative. Student nurse was able to get through the barrier of communication ( e.g. in her case, the client’s significant other ; because student nurse has difficulty communicating with the client whenever the significant other is around because client expects the significant other to answer for her). Client was able to interact well and was able to assess whether the client has learned something from the previous interactions. Client has improved a great deal since the first interaction as evidenced by more productive and fruitful conversations as time went by. 91 V. Evaluation and Recommendation Many studies of short term out-patient treatment over a six-month to two-year period indicate that people addicted to cocaine have a better chance of recovering than people who are addicted to heroin. Somehow, April’s being a young adult at the time she was admitted is working to her advantage because it is during this time that a significant other or care giver can guide and support her with her chosen lifestyle. Later than this stage, it is much harder to convince her to change her lifestyle because she may have already chosen one for herself. Up to this point, the best recommendation in this case would be to follow Dr. Yazar’s advice to transfer April to a drug rehabilitation center wher3e needs and therapies specific for her condition can be provided. Given her economic status, an appropriate rehabilitation center should be chosen . One that will not cost the family too much since April has three 92 siblings, one of which is still going to school. An expensive rehabilitation center would further pull down the family’s already unstable financial status. VI. Evaluation and Implication of this Case Study to: Nursing Practice In the nursing practice, it is vital that with the increasing number of stressors in the environment and an easy access to drugs, addictive or not, professions in the medical field are more prone to being a drug dependent due to the easy access to medications. The nurse should know how to recognize the signs and symptoms of drug dependence if ever they see one not only to promote the integrity of their profession but also for the benefit of their clients. Nursing Education Since most of the client’s significant others are directly affected with the effects and social repercussions of the condition, it is important to learn and understand this condition in order to impart adequate and understandable information to them. Knowledge is important in order to effectively intervene in the management of signs and symptoms in collaboration with reorientation and pharmacotherapy. Nursing Research 93 The human mind is a subtle and mysterious part of the human body; cannot be adequately fathomed by the human intellect. Researchers may so much as theorize as to the factors, signs and symptoms of substance abuseinduced psychosis but the larger part of the condition lies largely unexplained. It differs from person to person and affects the society in varied ways. This nursing research aims to give us a peek of what it is like in April’s world not only for a more holistic care but also to help prevent another innocent life wasted by illegal drugs. VII. Bibliography Davis, F.A. Taber’s Cyclopedic Medical Dictionary. California: 20th edition Kozier, Barbara, et al. Fundamentals of Nursing: Concepts, Processes and Practice. Philippines: Pearson Education South Asia Inc., 2004 Marieb, Elaine. Essentials of Human Anatomy and Physiology. Philippines: Pearson Education South Asia Inc., 2004 Shives, Rebeccca. Concepts of Psychiatric-Mental Health Nursing. Philippines: Lippincott Williams ans Wilkins, 2002 Videbeck, Shiela. Psychiatric Mental Health Nursing. Philippines: Lippincott Williams and Wilkins, 2002