Psych Protocol


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Psych Protocol

  1. 1. MENTAL HEALTH PSYCHIATRIC NURSING and Case Protocol Report
  2. 2. Psychodynamics Rehabilitation Research Updates Nursing Care Plans Prognosis Others Bipolar Mood Disorder Borderline Personality Disorder
  3. 3. <ul><li>She was born from an unwanted pregnancy. Patient was born healthy and exclusively breastfed for three (3) months. </li></ul><ul><li>During this period, the patient’s parents had frequent fights (mother being physically maltreated) . The father would always go home drunk. </li></ul><ul><li>The mother decided to work abroad as a cashier in Saipan </li></ul><ul><li>Claudia and her three sisters were left to the care of their grandmother and step grandfather in Rizal. </li></ul><ul><li>Before the patient turned one (1) year old, her sisters were fetched by their father to stay with him in Cavite. </li></ul><ul><li>In 1991, her mother visited. At that time, her mother was with her 1 st boyfriend. Claudia claims that she was molested by her mother’s 1 st boyfriend at 1 year of age. </li></ul>INFANCY (0-12 months)
  4. 4. Analysis of client’s data <ul><li>Breastfed for 3 months. </li></ul><ul><li>Considered grandmother as primary caregiver </li></ul><ul><li>Pessimism towards the experiences happBning in her life </li></ul><ul><li>Envious whenever her sister gave more importance and attention to other people </li></ul><ul><li>Very competitive </li></ul><ul><li>Didn’t exhibit oral fixation </li></ul>Theory <ul><li>1 ST STAGE: THE ORAL STAGE (0-18 months) </li></ul><ul><li>The Oral Cavity is the primary focus of libidal energy. </li></ul><ul><li>Preoccupied in sucking </li></ul><ul><li>Dependent on caretakers </li></ul><ul><li>Primary conflict is weaning </li></ul><ul><li>If not fully satisfied: </li></ul><ul><li>Frustrated oral character: pessimism, envy, suspicion and sarcasm. </li></ul><ul><li>Overindulged oral character : optimistic, gullible and full of admiration for others around him. </li></ul><ul><li>Oral fixation: drinking, eating, smoking or nail biting. </li></ul>
  5. 5. Analysis of client’s data <ul><li>Unwanted pregnancy </li></ul><ul><li>3 months left to Saipan </li></ul><ul><li>Before 1 year old, left to grandmother as primary caregiver. Lost contact with family members. </li></ul><ul><li>Results: </li></ul><ul><li>Inconsistency and emotional and physical unavailability of mother develops mistrust but was compensated by the grandmother. </li></ul>Theory <ul><li>TRUST vs. MISTRUST </li></ul><ul><li>Infancy (0 to 12 months) </li></ul><ul><li>Centers infant’s basic needs </li></ul><ul><li>Dependent on parents, especially mother </li></ul><ul><li>If exposed with warmth, regularity, and affection, infant’s view of the world is trust. </li></ul><ul><li>TRUST- dependable and reliable </li></ul><ul><li>MISTRUST- undependable and unpredictable </li></ul>
  6. 6. Analysis of client’s data <ul><li>  Her primary needs were not gratified at this stage of development. </li></ul><ul><li>client was breastfed by her mother for only 3 months </li></ul><ul><li>She lost contact with her father and sisters </li></ul><ul><li>Was left with the grandmother to whom she got closer relationship </li></ul><ul><li>Client developed anxiety early as a result of inadequate care because self-concept was not fully satisfied. </li></ul>Theory <ul><li>INFANCY (Birth up to 1 year) </li></ul><ul><li>Major developmental task: others will satisfy needs. </li></ul><ul><li>Infant learns to rely on caregivers to meet needs & desires </li></ul><ul><li>Primary need: bodily contact and tenderness </li></ul>
  7. 7. Theory <ul><li>Normal autistic Phase: Birth to 1 month </li></ul><ul><li>At this stage autism is normal. Unaware of anything but its own needs. </li></ul><ul><li>The mother needs to be available and lovingly meet the baby’s needs. </li></ul><ul><li>State of half-asleep, half-awake </li></ul><ul><li>Major task is to achieve homeostatic equilibrium with the environment </li></ul>Analysis of client’s data <ul><li>Born healthy and was exclusively breastfed for 3 months. </li></ul><ul><li>The mother was able to meet the needs of patient C during this stage because homeostatic equilibrium of the environment was met. </li></ul>
  8. 8. Theory <ul><li>Normal Symbiotic Phase: 1 to 5 months </li></ul><ul><li>Begin to learn about their world and develop their very first human bond. </li></ul><ul><li>the infant to develop trust </li></ul><ul><li>Awareness of caregiver </li></ul><ul><li>“ Social smile characteristics” </li></ul>Analysis of client’s data <ul><li>Sudden shift of primary caregiver. </li></ul><ul><li>Her mother left </li></ul><ul><li>Was not able to feel secure and comfortable. </li></ul><ul><li>As a residual trait she was engaged to different relationships due to the lack to parental image on whom she should depend on. </li></ul>
  9. 9. Theory <ul><li>Separation-Individuation Phase </li></ul><ul><li>Differentiation: 5 to 10 months </li></ul><ul><li>“ hatching phase” </li></ul><ul><li>interest on both the mother and the outside world </li></ul><ul><li>First outward signs of separation anxiety </li></ul><ul><li>If the mother is too neurotic, and needs the infant to focus on her needs, it interferes with normal development. </li></ul>Analysis of client’s data <ul><li>Grandmother as primary caregiver </li></ul><ul><li>Achieved hatching phase by beginning to explore the outside world rather than by just looking at her grandmother </li></ul><ul><li>No separation anxiety on the first day of school </li></ul>
  10. 10. Theory <ul><li>Separation-Individuation Phase </li></ul><ul><li>Practicing: 10-16 months </li></ul><ul><li>Mobility increases and able to explore the environment with autonomy. </li></ul><ul><li>Not ready for extended separation from the mother </li></ul><ul><li>Overprotectiveness may delay this phase. Don't push the child, and don't hold it back. </li></ul>Analysis of client’s data <ul><li>Her mother was back with her first boyfriend. </li></ul><ul><li>Probability of confusion of primary caregiver and the lack of attention to her because of the presence of the boyfriend of her mother. </li></ul><ul><li>Independent exploration of the environment was not done because the mother was not around to watch over her due to her preoccupation to her boyfriend. She had no assurance and comfort. </li></ul>
  11. 11. TODDLER (1-3 years old)
  12. 12. Analysis of client’s data <ul><li>Described herself as “oc-oc” </li></ul><ul><li>Passive-aggressive during the course in the ward </li></ul><ul><li>Anal retentive by being neat and orderly with her belongings </li></ul>Theory <ul><li>2 ND STAGE: THE ANAL STAGE (18 months-3 years) </li></ul><ul><li>obsession with the anus and with the retention or expulsion of the feces. </li></ul><ul><li>learns to control anal stimulation </li></ul><ul><li>If not fully met: </li></ul><ul><li>Anal expulsive character :generally messy, disorganized, reckless, careless and defiant. </li></ul><ul><li>Anal retentive character : neat, precise, orderly, careful, stingy, withholding, meticulous, and passive-aggressive. </li></ul>
  13. 13. Analysis of client’s data <ul><li>Consistent of doubting her potential capacity </li></ul><ul><li>feelings of resentment of always being unable to ‘good enough’ towards her mother </li></ul><ul><li>No control on impulses </li></ul><ul><li>Can’t reject leadership in school </li></ul><ul><li>Submissive to mothers decision all the time </li></ul>Theory <ul><li>AUTONOMY vs. SHAME AND DOUBT </li></ul><ul><li>Toddlerhood (13 months to 3 years) </li></ul><ul><li>Gains control over eliminative and motor abilities </li></ul><ul><li>Explore surroundings </li></ul><ul><li>Develop self-sufficient behavior </li></ul><ul><li>AUTONOMY- handle problems on their own, through parents encouragement </li></ul><ul><li>SHAME AND DOUBT- refusal of parents to let them perform the task which they are capable </li></ul>
  14. 14. Theory <ul><li>CHILDHOOD (1 to 5 years old) </li></ul><ul><li>Major developmental task: delay of gratification of needs. </li></ul><ul><li>she learns to accept it </li></ul><ul><li>development of speech and improvement of communication </li></ul>Analysis of client’s data <ul><li>No communication with mother and father, therefore was not able to improve her way of communication </li></ul><ul><li>No approval from mother and father therefore there delay of gratification of needs was not recognized. </li></ul>
  15. 15. Theory <ul><li>Separation-Individuation Phase </li></ul><ul><li>Rapprochement: 16 to 24 months </li></ul><ul><li>Ambitendency </li></ul><ul><li>get a real sense that they are individuals, separate from their mothers </li></ul><ul><li>emotional needs are not automatically sensed </li></ul><ul><li>Rapprochement crisis- wanting to be soothed by other and yet not be able to accept her help </li></ul><ul><li>&quot;terrible twos&quot;. Defiance and push too much </li></ul>Analysis of client’s data <ul><li>Mother was known to be strict. </li></ul><ul><li>needs were not met during this stage because of the preoccupation of her mother to her work and boyfriend that resulted to her temper tantrums. </li></ul><ul><li>She also wanted to be taken care of by her mother but was not able to accept it because she wanted something else. </li></ul>
  16. 16. Theory <ul><li>Separation-Individuation Phase </li></ul><ul><li>Consolidation and Object Constancy: 24- 36 months </li></ul><ul><li>More comfortable separating from their mothers </li></ul><ul><li>child can tolerate delay and endure separations </li></ul><ul><li>Beginning of conscience. If handled wrongly, development of pathological shame and guilt </li></ul><ul><li>Beginning of ego development. Some children at this stage will actively seek the father, fear being re-engulfed by the mother. </li></ul>Analysis of client’s data <ul><li>She thought of not being good enough on her mother , constant failure in getting the attention of her mother. </li></ul><ul><li>wrongly handled conscience which developed pathological shame and guilt, “i’m not good enough” </li></ul><ul><li>The absence of the father made her depend more on her mother. </li></ul>
  17. 17. <ul><li>Biological father- dead </li></ul><ul><ul><li>presumed dead </li></ul></ul><ul><li>Grandmother </li></ul><ul><li>Montalban: played with cousins (4-5 years older) </li></ul><ul><li>Mother had 1 st and 2 nd boyfriend (Austin) at that time </li></ul><ul><li>Did not attend kindergarten </li></ul>PRE-SCHOOL AGE (3-6 years old)
  18. 18. Analysis of client’s data <ul><li>Grandmother </li></ul><ul><li>No development of Electra </li></ul><ul><li>complex </li></ul><ul><li>Phallic character: proud and </li></ul><ul><li>Vain of accomplishments </li></ul><ul><li>Does not want to depend on </li></ul><ul><li>anyone for feelings </li></ul><ul><li>Reckless </li></ul><ul><li>Attraction to same-sex. </li></ul>Theory PHALLIC STAGE The primary focus of the libido is on the genitals. Unconscious desire to possess the opposite-sexed parent and to eliminate the same-sexed one. Boys: Oedipal complex Girls: Electra complex Goal: Identification process   If not accomplished: Phallic character Afraid or incapable of intimate relationships weak or confused sexual identity
  19. 19. Analysis of client’s data <ul><li>Playmates </li></ul><ul><li>Lack of communication </li></ul><ul><li>Social relations </li></ul><ul><li>Caregiver </li></ul><ul><li>Relationship with mother </li></ul><ul><li>Showing off </li></ul>Theory <ul><li>INITIATIVE vs. GUILT </li></ul><ul><li>Virtue: Purpose </li></ul><ul><li>Stage of energetic learning </li></ul><ul><li>INITIATIVE- independence in planning and undertaking activities </li></ul><ul><li>GUILT- pursuit of independent activities is discouraged </li></ul><ul><li>Significant = basic family </li></ul><ul><li>Achieved = assertive/conscience </li></ul><ul><li>Not = lacks self-confidence, pessimistic </li></ul><ul><li>Residual conflict: paralysis and inhibition, or overcompensation and showing off.   </li></ul>
  20. 20. Theory <ul><li>CHILDHOOD </li></ul><ul><li>Delay of gratification of needs </li></ul><ul><li>Speech and communication </li></ul>Analysis of client’s data <ul><li>Father </li></ul><ul><li>Grandmother </li></ul><ul><li>Cousins </li></ul><ul><li>Mother’s relationships </li></ul><ul><li>Skipped kindergarten </li></ul>
  21. 21. <ul><li>In 1997, at 7y/o, Claudia and her mother transferred residence to Makati (with Austin, 3 step-uncles, grandmother) </li></ul><ul><li>Her mother’s 2 nd boyfriend supported Claudia and her mother throughout her elementary years. </li></ul><ul><li>During this period, the patient claims that she was sexually molested by two of her step-uncles and was verbally and physically abused by her 3 rd step-uncle. </li></ul><ul><li>“ madalas nasa loob lang ako ng kwarto, hindi ako lumalabas ng kwarto kasi yung mga tito ko at mga cousins ko na gumalaw sa akin. Another thing, kung gagawa ka ng mga desisyon sa bahay, kailangan mo muna silang kunsultahin.” </li></ul>SCHOOL AGE
  22. 22. <ul><li>Education: </li></ul><ul><ul><li>Claudia attended Elementary School, skipping kindergarten. </li></ul></ul><ul><ul><li>No separation anxiety was noted upon entering school for the 1 st time. </li></ul></ul><ul><ul><li>Claudia was an achiever all throughout grade school. </li></ul></ul><ul><li>Social History: </li></ul><ul><ul><li>She had friends and was active in different activities. </li></ul></ul><ul><ul><li>When she was in grade four, she met Mina, who is her best friend up until now. She said that Mina accepted her for who she was. </li></ul></ul><ul><ul><li>She started being a leader when she was in Grade 4 upon being elected as the Vice-President of the class. </li></ul></ul><ul><ul><li>She claims that as a leader, she sticks to the rules and regulations. </li></ul></ul><ul><ul><li>Hobbies and interests: She claimed that she likes to play basketball, badminton and drawing. </li></ul></ul>SCHOOL AGE
  23. 23. Theory Analysis of Client’s Data <ul><li>Major developmental task - development of social and communication skills and self-confidence </li></ul><ul><li>  </li></ul><ul><li>Time of exploration in which the sexual energy is still present </li></ul><ul><li>Directed into other areas such as intellectual pursuits and social interactions </li></ul><ul><li>Same-sex friendships, hobbies, and other interests </li></ul><ul><li>Unparalleled repression of sexual desires and libidal interests </li></ul>Client was able to develop her social and communication skills and confidence.   Her interests and energy was directed in areas of intellectual pursuits and social interactions based on her academic and extra-curricular achievements Achiever – consistent top ten and Vice President of her class   Same-sex friendships was also established through closed ties with same-sex peers
  24. 24. Theory Analysis of client’s data <ul><li>INDUSTRY vs. INFERIORITY </li></ul><ul><li>School age (6 to 12 years) </li></ul><ul><li>(Virtue: Method and Competence) </li></ul><ul><li>critical for the “development of self-confidence” </li></ul><ul><li>Major developmental task : achieve a sense of personal and interpersonal competence through the acquisition of intellectual and social skills </li></ul><ul><li>A sense of accomplishment : </li></ul><ul><li>cooperate with others, and to cope effectively with people </li></ul><ul><li>Reinforcements-encouragement and stimulation </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>Claudia effectively achieved industry. She demonstrated by being diligent, persevering at tasks until are completed, and putting work before pleasure.   She was encouraged to make and do things and then praised for her accomplishments   She discovered and developed her own capabilities and strengths and unique potential thus making her feel confident. She set high standards for herself by focusing on her studies and strictly adhering to rules.
  25. 25. Theory Analysis of client’s data <ul><ul><li>JUVENILE (6 to 8 years old) </li></ul></ul><ul><ul><li>  Major developmental task: Begin the formation of relationship with peer groups. </li></ul></ul><ul><li>  </li></ul><ul><ul><li>Need for playmates and the beginning of healthy socialization. </li></ul></ul><ul><li>  </li></ul><ul><ul><li>This milestone is accomplished when she learns to cooperate, compete and compromise. </li></ul></ul><ul><li>The client was not able to fulfill her major developmental task. She was unable to form relationships with peer groups. </li></ul><ul><li>  </li></ul><ul><li>The client did not create peer relationships since they transferred residence and she frequently stays inside her room. </li></ul><ul><li>  </li></ul><ul><li>RESULT: Her experience of transferring residence and claiming that she was sexually molested, verbally and physically abused made her to stay inside her room frequently resulting to being alone and having unhealthy socialization and not fulfilling formation of relationship with peer groups. These experiences made her feel the lack of security and need for love and belongingness. This may signify the start of her neediness for other person that will be manifested in later stages. </li></ul>
  26. 26. Theory Analysis of client’s data <ul><li>PREADOLESCENT (9 to 12 years old) </li></ul><ul><li>Major developmental task: ability to relate successfully and form close relationships with peers, most especially with the same sex </li></ul><ul><li>  </li></ul><ul><ul><li>This relationship will later assist the child in feeling worthy and likable.  </li></ul></ul>The client’s major developmental task was met. She was successful in forming close relationships with same sex peers. The client was able to further deepen her relationship with same sex since she met girl M, who became her best friend. Another reason she was able to form relationships with peers was because she was active in different activities in school.   RESULT: The client was able to find a good relationship with a peer of the same sex.
  27. 27. <ul><li>CLIENT’S DATA </li></ul><ul><ul><ul><li>Attracted to same sex (guidance counselor, church leaders, girlfriend, eldest sister) </li></ul></ul></ul><ul><ul><ul><li>Mother did nothing when she told she was molested </li></ul></ul></ul><ul><ul><ul><li>Rebellious acts (cut classes, stole a book) </li></ul></ul></ul><ul><ul><ul><li>Private all girl school, then public school </li></ul></ul></ul><ul><ul><ul><li>High expectations for her = pressured </li></ul></ul></ul><ul><ul><li>Mother controls and influences her decisions. </li></ul></ul><ul><ul><li>Mother had 3 bf’s at a time </li></ul></ul><ul><ul><li>Banned from the church </li></ul></ul><ul><ul><li>Hurting self/suicide attempts </li></ul></ul>ADOLESCENT
  28. 28. THEORY ANALYSIS <ul><li>FREUD </li></ul><ul><li>5 th STAGE: THE GENITAL STAGE (11 yrs – onwards) </li></ul><ul><li>Strong sexual interest in the opposite sex </li></ul><ul><li>Goal is to establish a balance between various life areas. </li></ul><ul><li>If the other psychosexual stages have been successfully completed, the individual will develop into a well-balanced, warm, and caring adult. </li></ul><ul><li>  </li></ul><ul><li>If this stage is not satisfied, the person might: </li></ul><ul><li>Become dependent to his/her parents </li></ul><ul><li>GENITAL STAGE NOT SATISFIED. </li></ul><ul><li>Client is attracted/ engaged to same sex relationship (guidance counselor, church leaders, girlfriend, eldest sister) </li></ul><ul><li>Life decisions: dependent </li></ul><ul><li>  </li></ul><ul><li>Client did not develop sexual interest in the opposite sex because: </li></ul><ul><li>The early stages of development of the client: </li></ul><ul><li>***oral stage-pessimistic </li></ul><ul><li>***anal stage-”oc-oc”, passive aggressive </li></ul><ul><li>*** phallic stage (Electra complex)-root cause of homosexuality, weak or confused sexuality, afraid or incapable of intimate relationships. </li></ul>
  29. 29. THEORY ANALYSIS <ul><li>ERICKSON </li></ul><ul><li>  </li></ul><ul><li>Adolescence (12 to 19 years) </li></ul><ul><li>IDENTITY vs. ROLE CONFUSION </li></ul><ul><li>identity formation – developing a stable, coherent picture of oneself that includes integrating one’s past and present experiences with a sense of where one is headed in the future </li></ul><ul><li>role confusion—mixed ideas and feelings about the specific ways in which they will fit into society- and may experiment with a variety of behaviors and activities </li></ul><ul><li>  </li></ul><ul><li>The tensions for an adolescent could be the following: knowing herself, knowing what to do with her life, fitting in groups and experiencing things. </li></ul><ul><li>ROLE CONFUSION </li></ul><ul><li>Struggle to belong, accepted ( banned from church) and attain expectations of mother, classmates) </li></ul><ul><li>Her rebellious acts showed experiment with a variety of behaviors and activities(cut classes, stole a book) </li></ul><ul><li>Dependent to other </li></ul><ul><li>When she feels worthless, pressured, being left, or not having what she wants, she hurts herself and attempts to kill herself. </li></ul>
  30. 30. THEORY ANALYSIS ERICKSON   <ul><li>Client did not have own identity because of: </li></ul><ul><li>Client’s life decision was controlled by mother </li></ul><ul><li>The early stages of development of the client: </li></ul><ul><li>***Infancy (inconsistent caregiver)- feeling of worthlessness, over trust- neediness </li></ul><ul><li>***toddlerhood (shame and doubt)- doubts herself, feelings of resentment, impulsive, wants to meet expectations </li></ul><ul><li>***Pre-school (guilt)-show off(strict and controlling people) </li></ul>
  31. 31. THEORY ANALYSIS <ul><li>SULLIVAN </li></ul><ul><li>  </li></ul><ul><li>EARLY ADOLESCENT (13 to 17 years old) </li></ul><ul><ul><li>learning and struggling to have a sense of identity which is separate and independent from parents. </li></ul></ul><ul><ul><li>formation of relationships with the opposite sex is a major task. </li></ul></ul><ul><li>LATE ADOLESCENT (18 to 22 years old) </li></ul><ul><ul><li>the need for friendship and need for sexual expression. </li></ul></ul><ul><ul><li>Establishing intimate, long-lasting relationship with someone of the opposite sex is a major task </li></ul></ul><ul><li>Client has difficulty in having a sense of identity. </li></ul><ul><li>Her sense of identity did not fully emerge because of too much expectation of other people and controlling of the mother. She felt pressured. </li></ul><ul><li>  </li></ul><ul><li>Client was not successful in forming intimate, long-lasting relationship with someone of the opposite sex. </li></ul><ul><li>She hated the opposite sex. She preferred the same gender. </li></ul><ul><li>  </li></ul><ul><li>Client claimed that she was molested and this have caused her to hate the opposite sex. </li></ul><ul><li>The early stages of development of the client </li></ul><ul><li>***infancy(inconsistent caregiver) “self concept”-anxiety </li></ul><ul><li>***toddler (no approval)-wants to gain approval </li></ul><ul><li>***juvenile(peer relationships)-neediness for others </li></ul>
  32. 32. Prognosis Research Data <ul><li>75–80% = attempt or threaten suicide, and between 8–10% are successful. </li></ul><ul><li>34.5% met the criteria for remission at 2 years, 49.4% at 4 years, 68.6% at 6 years, and 73.5% over the entire follow-up.  </li></ul><ul><li>Only 5.9% of those with remissions experienced recurrences </li></ul><ul><li>Had previous episodes of suicide attempts </li></ul>
  33. 33. Prognosis Research Data <ul><li>Higher incidence of many medical conditions, including diabetes (58%-overweight/26%-obese), migraine headaches(77%), and hypothyroidism (common in women). </li></ul><ul><li>Family matters </li></ul><ul><li>Borderline personality has a good prognosis as long as those suffering from it stick to a diverse course of treatment </li></ul><ul><li>peaks in young adulthood and frequently stabilizes after age 30 </li></ul><ul><li>No diabetes, migraine and hypothyroidism, but is at risk. </li></ul><ul><li>Not supportive and there is rejection </li></ul><ul><li>Has history of noncompliance </li></ul><ul><li>Present age-20 </li></ul>
  34. 34. Prognosis Research Data <ul><li>Bipolar patients = higher mortality rates from suicide, heart problems and death. </li></ul><ul><li>Bipolar II = high rates of suicide </li></ul><ul><li>Bipolar II = depressive phase (Akiskal and Kessler, 2007) </li></ul><ul><li>pre- and early adolescent children with bipolar disorder = more severely ill </li></ul><ul><li>Children = higher risk for mixed mania, and a long duration of illness without well periods. </li></ul><ul><li>13% = no insurance and 15% = unable to afford medical treatment. </li></ul><ul><li>60% = substance abuse </li></ul><ul><li>Noncompliance to previous medications </li></ul><ul><li>High risk for suicide </li></ul><ul><li>In a present depressed state </li></ul><ul><li>Diagnosed at the age of 17 </li></ul><ul><li>Family is not financially stable </li></ul><ul><li>Does not exhibit signs of substance abuse </li></ul>
  36. 36. Rehabilitation or treatment of patients with bipolar disorders should be directed toward several goals: First, safety must be guaranteed. Second, a complete diagnostic evaluation of the patient is necessary. Third, a treatment plan that addresses not only the immediate symptoms but also the patient’s perspective well-being should be initiated.
  37. 37. <ul><li>Hospitalization </li></ul><ul><li>clear indication of hospitalization is the risk of suicide </li></ul><ul><li>patient’s grossly reduced ability to get food and shelter and the need for diagnostic procedures. </li></ul><ul><li>History of rapidly progressing symptoms </li></ul><ul><li>rupture of patient’s usual support system </li></ul>
  38. 38. <ul><li>II. Psychosocial Therapy </li></ul><ul><li>1. Cognitive therapy </li></ul><ul><li>Focuses on cognitive distortions postulated to be present in major depressive disorder </li></ul><ul><li>The goal is to alleviate depressive episodes and prevent their recurrence. </li></ul><ul><li>Studies show that cognitive therapy is equal in efficacy to pharmacotherapy. Also, the combination of the two is more efficacious than either therapy alone. </li></ul>
  39. 39. <ul><li>2. Interpersonal Therapy </li></ul><ul><li>Based on two assumptions. First, current interpersonal problems are likely to have their roots in early dysfunctional relationships. </li></ul><ul><li>Second, current interpersonal problems are likely to be involved in precipitating current depressive symptoms. </li></ul>
  40. 40. <ul><li>3. Behaviour therapy </li></ul><ul><li>Maladaptive behavioural patterns result in a person’s receiving little positive feedback and perhaps outright rejection from society. By addressing these behaviours in therapy, patients learn to function in the world in such a way that they receive reinforcement. </li></ul>
  41. 41. <ul><li>4. Psychoanalytically Oriented Therapy </li></ul><ul><li>This is based on the theories about depression and mania. It is to effect a change in a patient’s personality structure or character, not to simply alleviate symptoms. </li></ul><ul><li>Improvements in interpersonal trust, capacity for intimacy, coping mechanism, the capacity to grieve, and the ability to experience a wide range of emotions are some of the aims of this therapy. </li></ul>
  42. 42. <ul><li>5. Family Therapy </li></ul><ul><li>Family therapy examines the role of the mood disordered member in the overall psychological well-being of the whole family </li></ul><ul><li>also examines the role of the family in the maintenance of the patient’s symptoms. </li></ul>
  43. 43. V. Pharmacotherapy <ul><li>treatment for bipolar disorders is divided into acute and maintenance phases. </li></ul><ul><li>involves the formulation of different strategies for the patient who is experiencing mania or hypomania or depression </li></ul>
  44. 44. <ul><li>1. Treatment of acute mania </li></ul><ul><li>It is the easiest phase of bipolar disorder. patients with mania are best treated in the hospital, where aggressive dosing is possible and an adequate response can be achieved within days or weeks. </li></ul><ul><li>Drug of choice for the patient was Clonazepam 2mg/tab ¼ tab ODHS and Resperidone 2mg/tab 1 tab BID </li></ul>
  45. 45. <ul><li>2. Treatment of Acute Bipolar Depression </li></ul><ul><li>Relative usefulness of standard antidepressants in bipolar illness remains controversial because of their propensity to induce cycling, mania or hypomania. </li></ul><ul><li>A fixed combination of olanzapine and fluoxetine has been shown effective in treating acute bipolar depression for an 8-week period. </li></ul>
  46. 46. <ul><li>3. Maintenance Treatment for Bipolar Disorder </li></ul><ul><li>Preventing recurrences of mood episodes is the greatest challenge facing the clinician. </li></ul><ul><li>Lithium, carbamazepine, and valproic acid, alone or in combination, are the most widely used agents in the long-term treatment of patients with bipolar disorder. Lamotrigine has prophylactic antidepressant and mood stabilizing properties. </li></ul><ul><li>Also thyroid supplementation is frequently necessary during long-term treatment. Many patients with lithium develop hypothyroidism and many patients with bipolar disorders develop idiopathic thyroid dysfunction. </li></ul>
  47. 47. <ul><li>VI. Depression Awareness, Recognition and Treatment Program </li></ul><ul><li>D/ART is a multiphase information and education program designed to alert health professionals and the general public to the fact that the depressive disorders are common, serious and treatable. </li></ul><ul><li>It was launched by NIMH in 1988 to enhance the availability and quality of treatment for depression. </li></ul>
  48. 48. NURSING CARE PLANS Risk for Suicide Anxiety Noncompliance Powerlessness Interrupted Family Processes Impaired Sexual Patterns Ineffective Coping Disturbed Thought Process Chronic Low Self Esteem Impaired Social Interaction
  49. 49. Risk for suicide attempt due to depression and feelings of rejection
  50. 50. The client’s depression may be rooted from the faulty family dynamics that the client experienced early on. These included her perceived loss of her father, causing her to blame herself and turn this anger inward; as well as her inability to achieve the extraordinarily high ideals her mother imposes on her. Ultimately, the client feels worthless and empty, urging her to take her own life. Her intense unstable relationships in her search for an identity which ends up in feelings of rejection from the other party threatens the client due to her fear of abandonment. Because of this, she commits suicide and other self-mutilating actions in order to avoid this feeling.
  51. 51. After 6 hours of nursing intervention, patient will: 1. Be safe from harm. 2. Verbalize her feelings and thoughts regarding her current situation and about suicide. After 6 weeks of nursing intervention, patient will: 1. Deal effectively with her thoughts and emotions that contribute to her suicidal ideations. 2. Be able to decide that suicide is not the answer to solve her problems. 3. Find alternative ways in controlling and expressing her emotions.
  52. 52. <ul><li>Subjective: </li></ul><ul><li>Patient verbalized, “…kapag naisipan ko ulit (to commit suicide).” </li></ul><ul><li>“… parang wala na saking epekto yung pagpapakamatay eh, kasi ilang beses na akong nagpapakamatay, buhay pa din ako.” </li></ul><ul><li>Objective: </li></ul><ul><li>Episodes of depression </li></ul><ul><li>Past attempts to commit suicide </li></ul><ul><li>- Slashed her wrist using a “paso” when she was 15 years old (2005) </li></ul><ul><li>- Drank milk with cuticle (January 23) </li></ul><ul><li>- Ingestion of one bottle of isopropyl alcohol (February 15) </li></ul><ul><li>- Ingested 100 tablets of Diphenhydramine (December 5, 2010) </li></ul>
  53. 53. <ul><li>Frequently observe the client. Monitor potentially dangerous devices such as eating utensils and such in the environment. </li></ul><ul><li>Discuss with the client her suicidal ideations. Ask the client if she has any plans of hurting herself. </li></ul><ul><li>Ask the client regarding her past suicide attempts and how did she feel about it. Evaluate client for any factors that may increase suicidal tendencies. </li></ul><ul><li>Express concern for her safety and nurse’s willingness to help her. </li></ul><ul><li>Promotes client’s safety and reduces risk for suicide. </li></ul><ul><li>To be able to know the plans of the patient regarding committing suicide and prevent its potential reoccurrence. </li></ul><ul><li>Identifies the client’s thoughts regarding suicide and her reasons behind it. </li></ul><ul><li>Makes her feel cared for and helps her find ways in expressing her feelings rather than committing suicide. </li></ul>
  54. 54. <ul><li>Encourage expression of feelings and make time to listen to concerns. </li></ul><ul><li>Allow to express angry feelings in a safe way (e.g. journal writing, painting, etc.) </li></ul><ul><li>Acknowledge reality of suicide as an option. Discuss the consequences of action if they follow through on intent. Ask how it will help the individual to resolve problems. </li></ul><ul><li>Acknowledge reality of feelings and that they are okay. Help them sort out thinking and begin to develop understanding of the situation and look for other alternatives. </li></ul><ul><li>Promotes healthy expression of feelings and diverts attention of the client. </li></ul><ul><li>Helps to focus on consequences of action and possibility of other options. </li></ul><ul><li>8. Promotes feelings of self-worth and improving sense of well-being. </li></ul>
  55. 55. <ul><li>Engage on physical activity programs. Releases endorphins which are helpful in elevating the mood of the client. </li></ul><ul><li>Negotiate contract with the client regarding willingness not to do anything lethal for a stated period of time. </li></ul><ul><li>Promotes feelings of self-worth and improving sense of well-being. </li></ul><ul><li>This will serve as a vow of the client that she will not harm herself during hospitalization and she will seek out help from the staff when contemplating suicide or any self-mutilating behaviors. </li></ul>
  56. 56. After implementing the interventions, the client was free from any harm. She was able to recognize her difficulties by openly saying her stories. Especially her hate to her mother. Client was able to open up her emotions to her mother which reconciled them both. She was able to see clearly that suicide was not the answer to her problems and eventually forgave everyone. The client found other outlets to express he emotions such as journal writing and painting. NCPs
  57. 57. Disturbed thought process related to altered perceptions of surrounding stimuli
  58. 58. Cognitive processes include those mental processes by which knowledge is acquired. These mental processes include reality orientation, comprehension, awareness, and judgment. A disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately.
  59. 59. <ul><li>Within one week, the client shall be able to: </li></ul><ul><li>With assistance from caregiver, client will maintain orientation to time, place, person, and circumstances for specified period of time. </li></ul><ul><li>Express thoughts and feelings related to altered perceptions </li></ul><ul><li>Identify specific behaviours which are inappropriate in real life situations </li></ul>
  60. 60. <ul><li>Within 6 weeks, the client will be able to: </li></ul><ul><li>Demonstrate reality-based perceptions, as evidenced by decreased verbalizations of hallucinations and delusions and decreased threats to self and others. </li></ul><ul><li>Client will demonstrate accurate perception of the environment by responding appropriately to stimuli indigenous to the surroundings. </li></ul>
  61. 61. <ul><li>Subjective: </li></ul><ul><li>Dec 6: According to the patient, she sometimes see strangers in the isolation room standing or leaning on the walls these people would disappear after she closes her eyes for a while. </li></ul><ul><li>Dec 10: She was seen crying, verbalizing, “May nakikita akong tao dun tinatawanan ako.” </li></ul><ul><li>She also stated seeing strangers in the isolation room standing or leaning on the walls and these people would disappear after she closes her eyes for a while. </li></ul><ul><li>  </li></ul>
  62. 62. O bjective:   The patient was noted to have crying spells in the middle of the night
  63. 63. <ul><li>Review social history with client. </li></ul><ul><li>Provide open environment in which the patient feels safe discussing her feelings </li></ul><ul><li>  </li></ul><ul><li>Provide protective supervision. Reassure safety if client responds with fear to inaccurate sensory perception. </li></ul><ul><li>To assess contributing factors, and acknowledgement of changes. </li></ul><ul><li>Helps patient to feel accepted in present condition without feeling judged, promotes sense of self dignity and control </li></ul><ul><li>The patient’s safety is a priority. The patient may be unable to accurately assess potentially dangerous items and situations such as wet floors, electrical appliances, etc. </li></ul>
  64. 64. <ul><li>Advise patient to communicate own thoughts and perceptions. Encourage expression of anger, fear, despair, loneliness and rejection without confrontation </li></ul><ul><li>U se concrete and direct words and avoiding gesturing so the patient is not threatened by the care provider. </li></ul><ul><li>Decrease the amount of stimuli in the client's environment (e.g., low noise level, few people, simple decor). </li></ul><ul><li>Helps identify the kind and extent of problems the client is exhibiting. Acceptance of feelings allows patient to begin to deal with situation </li></ul><ul><li>Validation of patient’s needs, thoughts, and perceptions will encourage trust and openness. </li></ul><ul><li>This decreases the possibility of forming inaccurate sensory perceptions. </li></ul>
  65. 65. <ul><li>Discuss content of the hallucinations to determine appropriate interventions. </li></ul><ul><li>Correct client's description of inaccurate perception, and describe the situation as it exists in reality. </li></ul><ul><li>Do not reinforce the hallucination. Let client know that you do not share the perception. Maintain reality through reorientation and focus on real situations and people. </li></ul><ul><li>The nurse may be able to take measures that will reduce the frequency of the hallucination (e.g., leaving the lights on, or the door open). </li></ul><ul><li>Explanation of, and participation in, real situations and real activities interferes with the ability to respond to hallucinations </li></ul><ul><li>Reality orientation decreases false sensory perceptions and enhances client's sense of self-worth and personal dignity. </li></ul>
  66. 66. <ul><li>Limit setting if demonstrated inappropriate/ maladaptive behaviour </li></ul><ul><li>Consider to have the same personnel/ nurse on a regular basis, if possible. </li></ul><ul><li>Encourage participation in group activities. </li></ul><ul><li>To control own feelings and protect others from harm </li></ul><ul><li>Provide a feeling of security and stability in the client's environment </li></ul><ul><li>To divert attention from perceptions of external stimuli without the actual presence of those stimuli </li></ul>
  67. 67. Within one week, the client is able to recognize when perceptions within the environment are inaccurate. T here was also decreased verbalization of inaccurate sensory perceptions. She responded positively in correcting inaccurate perceptions and restoring reality to the situation.   Within 6 weeks, the client was fairly kempt, oriented to time, place and person, with appropriate mood and affect. She had no hallucinations and suicidal ideations. She actively participated in daily therapy and activities . She was able to maintain reality through reorientation and focusing on real situations and people. NCPs
  68. 68. Powerlessness due to perceived lack of control over life decisions
  69. 69. Powerlessness is a perception that one's own action will not significantly affect an outcome. It is the perceived lack of control over a current situation or happening. Powerlessness occurs among clients with bipolar disorders (currently on depression) and borderline personalities. The client experiences an alteration in cognition in which they have a depressed mind filled with anxiety, doom and gloom, and fear. They think that their own action will not significantly affect the outcome of things.
  70. 70. <ul><li>After 1 day, the patient will be able to: </li></ul><ul><li>Recognize and verbalize feelings and thoughts contributing to the feeling of powerlessness. </li></ul><ul><li>Discuss the coping mechanisms used when confronted with similar situations. </li></ul><ul><li>After 1 week, the patient will be able to: </li></ul><ul><li>Demonstrate a reduced feeling of powerlessness through expressing a sense of control over her sexual tendencies </li></ul><ul><li>Identify and use effective coping mechanisms to counteract feelings of powerlessness </li></ul>
  71. 71. <ul><li>Subjective </li></ul><ul><li>Client verbalized that she lacks the will to refrain from acting on her sexual urges towards her elder sister. </li></ul><ul><li>Client verbalized that it was her mother who makes decisions for her. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul><ul><li>Objective </li></ul><ul><li>Kissing her sister and having a sexual relationship with her </li></ul><ul><li>Her drawing of broken parallel lines (interpreted as her broken dreams that can no longer be achieved due to her condition) </li></ul>
  72. 72. <ul><li>Assess other situational factors that may compound with the feeling of powerlessness. </li></ul><ul><li>Encourage verbalization of feelings and perception regarding her situation. </li></ul><ul><li>Help client identify situations in which she has control against those that are not within her control. </li></ul><ul><li>Identifies the other contributing factors to situation that may need resolution as well. </li></ul><ul><li>Creates a supportive environment for the client and determines her perception on the perceived lack of control. </li></ul><ul><li>Promotes a sense of control over her condition and support a hopeful feeling. </li></ul>
  73. 73. <ul><li>Encourage client to maintain a sense of perspective about the situation. </li></ul><ul><li>Provide situations wherein she can take control and make decisions such as involving her in simple decision making, giving information, etc.  </li></ul><ul><li>Discuss with client her response when confronted with thoughts that she feel powerless to. </li></ul><ul><li>Assist client in adapting coping mechanisms that will help her gain control of a similar situation. </li></ul><ul><li>Helps increase the client’s sense of control over her own will. </li></ul><ul><li>Exercises her decision-making ability and encourages responsibility for her own self and actions. </li></ul><ul><li>Identifies the coping mechanism that the client uses in such situations. </li></ul><ul><li>Helps client to deal effectively and increase feeling of control with stressful situations. </li></ul>
  74. 74. Within the day, the patient was able to verbalize her own feelings and perceptions that contribute to her feeling of powerlessness over her own thoughts. She discussed what she did when she is feeling sexually attracted towards her sister. After a week, the patient was able to verbally express a feeling of control over her own sexual tendencies, stating that she knows that she has choice and she can choose not to act on such thoughts. She is aware that she is responsible for her own actions. She said that the next time she is in such situation; she will deal with it by putting mind over matter. NCPs
  75. 75. Interrupted family processes related to situational crises of having a broken family and a lack of support mechanisms
  76. 76. Before the client turned one year old, she was left by her parents to her grandmother, who brought her up. She grew up to the reality that her biological father was dead (even though he wasn’t) and her mother having different boyfriends every time. She had same sex preferences which led to her rejection from her church community, school and the like. Every time she would verbalize something wrong that happened to her, she would just get scolded. She never had the support she needed. All these factors contributed to the family’s altered processes which results to the prevention of the development of the family.
  77. 77. <ul><li>After 3 days of nursing interventions, the client and her family will: </li></ul><ul><li>Verbalize understanding of situation. </li></ul><ul><li>Demonstrate involvement in problem-solving processes directed at appropriate solutions for certain situations. </li></ul><ul><li>Note cultural/ religious factors that may have affected their family relationship. </li></ul><ul><li>Acknowledge difficulties and realities of their family situation </li></ul><ul><li>After 2 weeks of nursing interventions, the client and her family will: </li></ul><ul><li>Express feelings freely and appropriately. </li></ul><ul><li>Stress importance of continuous open dialogue among family members. </li></ul>
  78. 78. <ul><li>Subjective: </li></ul><ul><li>Relationship with father: Client verbalized, “Okay naman kami, pero hindi ganoon ka-okay. Money lang kasi lagi niyang nasa isip eh…” </li></ul><ul><li>Relationship with mother: Client verbalized, “…Pakiramdam ko hindi niya ko mahal.” </li></ul><ul><li>Relationship with sister: The patient said that her sister’s lack of belief in her caused her to take the 10 tablets of Diphenhydramine and her sister loves her but does not want to embrace her or have any physical contact. </li></ul><ul><li>During her stay in Makati, she verbalized, “madalas lang akong nasa loob ng kwarto kasi yung mga tito at mga cousins ko na gumagalaw sa’kin. Another thing, kung gagawa ka ng mga desisyon sa bahay, kailangan mo muna silang konsultahin.” </li></ul>
  79. 79. <ul><li>Objective: </li></ul><ul><li>Client was left by parents to grandmother before the age of 1. </li></ul><ul><li>No emotional support from family members </li></ul><ul><li>Rejection from people (Laureen and community members, previous high school, etc.) </li></ul><ul><li>Parents are not in good terms. </li></ul><ul><li>Blamed mother for having a dysfunctional life due to having many boyfriends at that time. </li></ul><ul><li>There is still a barrier between her and her eldest sister. There is no physical contact between the two. </li></ul>
  80. 80. <ul><li>Observe patterns of communication in family. </li></ul><ul><li>Identify how the client’s difference in religion (Christian) may have affected her relationship with her family through one-on-one interactions. </li></ul><ul><li>Know the client’s and the family members’ difficulties of their relationship through activity therapies, such as art therapy or drawing of feelings. </li></ul><ul><li>Identifies weakness or areas of concern to be addressed as strengths that can be used for resolution of problem. </li></ul><ul><li>This may affect perceptions of family members towards other members. </li></ul><ul><li>This can help the family to know the feelings they have for each other if they have a problem verbalizing them to one other. </li></ul>
  81. 81. <ul><li>Encourage expression of anger. Avoid taking comments personally. </li></ul><ul><li>If possible, facilitate, weekly family meetings, increasing in frequency gradually. </li></ul><ul><li>Allows the client to verbalize feelings. Maintains boundaries between nurse and family. </li></ul><ul><li>To facilitate ongoing problem solving and to be able to verbalize to each other concerns and to involve family in planning for future and mutual goal setting. </li></ul>
  82. 82. <ul><li>After 1 week of nursing interventions, the client and her family: </li></ul><ul><li>Client said that her relationship with her mother is better and she has forgiven her uncles. </li></ul>NCPs
  83. 83. Ineffective sexual patterns related to perceptions of own sexuality as evidenced by inappropriate sexual behaviours
  84. 84. Sexual Patterns, Ineffective: Expressions of concern regarding own sexuality Early in her life, patient had already developed homosexual preferences. She had been preoccupied with ideations of sexual intimacy with people of the same gender. She has 3 sisters, whom she did not grow up with. When her eldest sister showed more support and care towards her, she then grew fond of her and pt. started to develop special intimate feelings towards her sister.
  85. 85. <ul><li>After three days, the client will be able to: </li></ul><ul><ul><li>demonstrate willingness in engaging conversation and express thoughts and feelings regarding sexuality </li></ul></ul><ul><li>After three weeks, the client will be able to:   </li></ul><ul><ul><li>Verbalize awareness of inappropriate sexual behaviours </li></ul></ul><ul><ul><li>Demonstrate sexually appropriate behaviour, as evidenced by a decrease in preoccupation with sexual thoughts </li></ul></ul><ul><ul><li>Adapt an activity which she can use to divert sexual energy </li></ul></ul><ul><li>  </li></ul>
  86. 86. <ul><li>Subjective </li></ul><ul><li>Because of the alleged sexual abuse, pt. claimed to have become a man hater and eventually developed feelings for the people of the same sex </li></ul><ul><li>12-6-10- During an interview, pt. mostly talked about her increased sexual drive (sexual relationship with her sister and girlfriend </li></ul><ul><li>1-10-11-Pt. talked about thinking of sex whenever she gets stressed </li></ul>
  87. 87. <ul><li>Objective </li></ul><ul><li>12-9-10-Holds hands with another female patient </li></ul><ul><li>12-10-10-Was often seen lying beside and hugging another female patient </li></ul><ul><li>12-20-10-Had delusions of having sex with her sister </li></ul><ul><li>Acts of masturbation </li></ul><ul><li>  </li></ul>
  88. 88. <ul><li>Provide an environment in which the patient feels safe discussing her feelings </li></ul><ul><li>Permit expression of anger, fear, despair, loneliness and rejection </li></ul><ul><li>Remain non-judgemental </li></ul><ul><li>Limit setting to address inappropriate/ maladaptive behaviour </li></ul><ul><li>  </li></ul><ul><li>Helps patient to feel accepted in present condition without feeling judged, promotes sense of self dignity </li></ul><ul><li>Acceptance of feelings allows patient to begin to deal with situation </li></ul><ul><li>Fosters acceptance towards understanding client </li></ul><ul><li>Helps client to know inappropriate/maladaptive behaviour and control it. It also protects others from being harmed. </li></ul>
  89. 89. <ul><li>Provide positive reinforcement for improvement in sexual behaviour. </li></ul><ul><li>Point out maladaptive sexual behaviours </li></ul><ul><li>Encourage participation and provide diversional activities that can be an outlet for sexual energy (doing crafts, painting) </li></ul><ul><li>  </li></ul><ul><li>5. Encourages continuation of desired behaviours and efforts to control self. </li></ul><ul><li>6. To help the patient focus in diverting actions into more accepted behaviours </li></ul><ul><li>Offering activities helps client divert sexual energy and can decrease preoccupation with sexual thoughts. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  90. 90. After three days, the client was conversant and was able to express her thoughts and feelings concerning her sexual desires. After three weeks, she employed diversionary activities that help her express sexual ideations in a healthy way. She displayed good insight and judgement as evidenced by her awareness of wrong behaviours she displayed. Her preoccupation on lustful acts was decreased. She actively participated in daily therapy and activities. NCPs
  91. 91. Moderate anxiety related to accumulation of stressful events
  92. 92. As the client was growing up, there were a lot of stressors that she experienced. She was rejected several times (by her eldest sister, Laureen, grandmother), high expectations of mother and did not have the attention she needed while she was growing up because of having an incomplete family. All these contributed to the client’s moderate anxiety: limited awareness of environmental stimuli, increased concentration, narrower perceptions.
  93. 93. <ul><li>After 8 hours of nursing interventions, the client will: </li></ul><ul><ul><li>Appear relaxed </li></ul></ul><ul><ul><li>Verbalize awareness of feelings of anxiety </li></ul></ul><ul><li>After 3 days of nursing interventions, the client will: </li></ul><ul><ul><li>Report anxiety is reduced to a manageable level </li></ul></ul><ul><ul><li>Identify healthy ways to deal with and express anxiety </li></ul></ul><ul><ul><li>Demonstrate problem-solving skills </li></ul></ul><ul><li>  </li></ul>
  94. 94. <ul><li>Subjective </li></ul><ul><li>Line of the client’s poem- Yakap ni Ina: “Nasasakal ako sa yakap mo ina..” </li></ul><ul><li>“… Tanong ko sa sarili ko, bakit ako, bakit hindi na lang iba, bakit kelangan kong huminto sa pag-aaral.” </li></ul><ul><li>Verbalized high expectations of mother, “…Minsan nagagalit pa siya kapag hindi ko naaabot mga hinihingi niyang expectations… pakiramdam ko hindi niya ko mahal…kelangan kapag kinompare ka, hindi ka-madown…” </li></ul>
  95. 95. <ul><li>Objective </li></ul><ul><li>Day 1: flight of ideas, looseness of association, suicidal ideation and sees strangers in isolation room </li></ul><ul><li>Day 2: poor eye contact </li></ul><ul><li>Day3: unreceptive to greetings, poor eye contact </li></ul><ul><li>Day 6: suicidal ideations </li></ul><ul><li>Day 8: crying spells in the middle of the night and head banging </li></ul><ul><li>Day 11: Blank stares and became anxious about her new clerk-in-charge </li></ul><ul><li>Day 13: very talkative </li></ul><ul><li>Day 15: Febrile , admitting having no sense of control when hurting herself, delusions of having sex with her sister </li></ul><ul><li>Restless episodes </li></ul><ul><li>Day 40: She didn’t sleep well. </li></ul><ul><li>Attention seeker   </li></ul>
  96. 96. <ul><li>Monitor vital signs (changes in blood pressure, increase in pulse rate, etc.) </li></ul><ul><li>Note reports of insomnia or excessive sleeping, limited/avoidance of interactions with others and be aware of defense mechanisms being used. </li></ul><ul><li>Identify the coping skills the individual is currently using (such as anger, daydreaming, etc.) and review coping skills used in the past. </li></ul><ul><li>To identify physical responses associated with both medical and emotional conditions. </li></ul><ul><li>This may be behavioral indicators of use of withdrawal to deal with problems and this may interfere with the ability to deal with problems. </li></ul><ul><li>To determine those that might be helpful in current circumstances or if not, may be corrected. </li></ul>
  97. 97. <ul><li>Encourage client to acknowledge and to express feelings </li></ul><ul><li>Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. </li></ul><ul><li>Provide accurate information about the situation. Allow the client to know her present situation. </li></ul><ul><li>  </li></ul><ul><li>This will show the client that she is accepted and feel that she is important because her feelings are being heard. </li></ul><ul><li>Help the client identify what is reality based and so she may know what her current situation is. </li></ul><ul><li>To limit degree of stress and avoid overwhelming or anxious client. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  98. 98. <ul><li>Provide comfort measures (provide calm environment) and modify procedures as much as possible (such as substituting oral for intramuscular medications). Manage environmental factors (harsh lighting, etc.). </li></ul><ul><li>Encourage client to develop an exercise/activity program. </li></ul><ul><li>  </li></ul><ul><li>To limit degree of stress and avoid overwhelming or anxious client. </li></ul><ul><li>This may serve to reduce the level of anxiety by relieving tension. This also may be a form of diversional activity for the client. </li></ul>
  99. 99. <ul><li>After 1 week of nursing interventions, the client: </li></ul><ul><ul><li>verbalized, “Naiinis kasi ako sa sakit ko pero may hope pa rin na makalabas dito.” </li></ul></ul>NCPs
  100. 100. Chronic low Self-esteem related to constant disapproval from significant others.
  101. 101. Patient experienced constant disapproval from her mother by constantly putting her down whenever she commits a mistake. Also her mother makes all the decision for her. She was also constantly left alone by the ones whom she admired because of her homosexual feelings towards them.
  102. 102. After 6 hours of nursing intervention, patient will: 1.Verbalize understanding of negative evaluation of self and reason for the problem 2.Verbalize thoughts about self worth After 6 weeks of nursing intervention, patient will : 1.Participate in treatment program to promote change in self-evaluation 2.Demonstrate behaviour changes to promote positive self-image 3.Participate in family/group/community activities to enhance change
  103. 103. Subjectve: at age 14, patient verbalized, “walang ginawa ang nanay ko pakiramdam ko hindi niya ako mahal.” Objective: 1. transferred to public school because of the rumours that she was molested. 2. banned by the church for two times because of sexual indiscretion and attempted suicide.
  104. 104. 1. identify family dynamics- present and past- and cultural influences. 2 discuss client perceptions of self-related to what is happening; confront misconceptions and negative talk 3. emphasize need to avoid comparing self with others. Encourage client to focus on aspects of self that can be valued. 4. Have client list current/past success and strengths 1. Family may be engaged in “put-downs” or “teasing” 2. Addressing these issues openly provides opportunity for change. 3. May help client see that he or she can develop an internal locus of control by recognizing these aspects of themselves 4. Assist client to develop internal sense of self-esteem
  105. 105. 5. use positive I-messages rather than praise 6. set limits on aggressive behaviour such as suicide attempts, preoccupation and rumination. 7. give reinforcements on progress noted 8. assist client to identify goals that are personally achievable 5. Raises the client's self esteem 6. Negative behaviours diminish sense of self-concept 7. Positive words of encouragement promote continuation of efforts, supporting development of coping behaviour 8. Increase likelihood of success and commitment to change
  106. 106. <ul><li>Client was open in narrating her feelings and experiences towards her mother and significant others. </li></ul><ul><li>Client participated well during the activities organized by the nurses. </li></ul><ul><li>Client became aggressive and hyperactive. </li></ul><ul><li>She had the chance to open up her feelings to her mother and was very much happy about that. </li></ul>NCPs
  107. 107. Impaired social interaction related to impulsivity and attention seeking behaviour
  108. 108. Some of the characteristics of the client’s disorder are impulsivity, elevated mood and attention seeking behaviour. The patient is impulsive which means that she acts on the slightest whim. This can be difficult for others because a person who is impulsive may have urges to say or do things which are socially unacceptable. The client also exhibits attention seeking behavior which is burdensome even for her relatives since it is time and energy consuming.
  109. 109. Within 3 days, the client shall be able to: 1.Observe own behavior in social interaction 2.Express thoughts and feelings regarding social interaction 3.Verbalize awareness of change in social interaction 4.Identify specific behavior that lead to poor social interaction 5.Express desire to be involved in achieving positive changes in social behaviours and participate in behavioral therapy before discharge, the client will be able to: 1. Comply with medications and treatment regimen 2. Achieve positive changes in social behaviourand interpersonal relationships
  110. 110. Subjective: -Verbalized that she has poor impulse control and gets easily frustrated -suicidal ideation, “ naglaslas ako nung naghiwalay kami” “ Ang mga sugat ko ako nagslash niyan sa hands ko, di ko kasi makontrol sarili ko” Objective: -Manipulation of conversation -attention seeking behavior -sexually preoccupied -loner who easily gets irritated and depressed
  111. 111. 1 . Observe and describe social behaviours in objective terms, noting speech pattern and body language. 2. Encourage client to verbalize perception on changes in social interaction. 3. Encourage the client to verbalize negative self concepts 1. Helps identify the kind and extent of problems the client is exhibiting. Allows the nurse to identify which social skills need to be enhanced or learned. 2. To identify and to help the client resolve negative self concepts . 3. Enhances comfort with new behaviours
  112. 112. 4. Role play random social situations. Start with one on one role playing with the nurse then small group interactions and then proceeding to large groups 5. Provide positive reinforcement for improvement in social behaviour. . 4. Allows the client to learn how to behave in social activities. Proceeding from simple to more complex interactions enhances learning and makes it less stressful for the client to adapt, 5. Encourages continuation of desired behaviours and efforts to control self.
  113. 113. Within 3 days the client was able to: -verbalize “kapag di maganda yung pakiramdam ko sa barkada hindi ko sinasamahan. Kapag din seryoso seryoso. Walang personalan pagdating sa mga trabaho.” -verbalize about the leadership seminar ” Nagsimula na akong magpa-pansin. May grandiose kasi ako nu’n. lagi akong nagtataas ng kamay kapag nagtatanong yung speaker. Lagi akong nagsasalita. Lahat ng contest noon sinalihan ko at very competitive din. Two poems na nagawa ko ay napublish. Pinagalitan ako ng mga fellow delegates noon kasi masyado daw akong mayabang. Sumama loob ko. Pagkauwi ko hindi na ako makatulog. Sobrang restless ko na. hindi ako mapakali. -Actively participate in daily therapy and activities and make several artworks which she bragged about to others. before discharge the client was able to: -show reduced symptoms of bipolar disorder and BPD - Reconcile her feelings with her mother. NCPs
  114. 114. Noncompliance to therapeutic regimen related to unhealthy client-health provider relationship
  115. 115. Client does not adhere to prescribed therapeutic regimen due to stressful life events leading to client’s perception of lack of social support. Due to lack of constant monitoring and proper encouragement regarding treatment, the client avoid compliance and at certain instances, even alters it signifying protest regarding an existing conflict between her and the primary care provider, or close people in her environment.
  116. 116. After one week, patient will be able to: 1)Understand the necessity of following prescribed therapeutic regimen 2) Voluntarily follow the schedule of taking the prescribed medications After one month, the patient will be able to: 1) Strictly comply to the prescribed schedule of taking her medications as evidenced by: increased therapeutic effect, maintained appoinments and reduced, if not absent, re-admissions.
  117. 117. <ul><li>Subjective </li></ul><ul><li>Client verbalized, </li></ul><ul><li>“ Uminom akong 10 tablets ng diphenhydramine tapos nahirapan akong huminga at dinala ako sa E.R pero hindi ako pinaniniwalaan ng doktor na ginawa ko iyon. Akala nila umaarte lang ako pero hindi naman kaya. Noong sumunod na araw uminom akong 100 tablets.” </li></ul><ul><li>Objective </li></ul><ul><li>Poorly compliant with her medications ( Depakote, Diphenhydramine, Essentiale ) for three (3) months (occasionally missing them for 2-3 days) </li></ul><ul><li>Excessive intake of Diphenhydramine (as means for suicide attempt) </li></ul><ul><li>Evidence of exacerbation of symptoms : recurrence of depressive episodes as evidenced by suicidal attempts </li></ul><ul><li>Hospital readmission </li></ul>
  118. 118. 1. Resolve existing conflicts between the patient and her provider (mother, eldest sister) 2. Discuss importance of complying with prescribed therapeutic regimen in her well-being 3. Facilitate close monitoring of the client by supervision of taking of medications and having regular pill counts. 4. As compliance improves, gradually reduce the amount of professional supervision and reinforcement. 1. This will aid in removing the barrier that restricts the patient from following the treatment plan accordingly. 2. To set standards for the client to be more encouraged in taking her medications 3. This will make the client aware of the necessity of following therapeutic regimen and thus, setting the limits as to her behavior towards such. 4. This will allow the client to develop her own sense of responsibility in taking her medications. This will also foster independence on her part.
  119. 119. The client during her stay in the ward was observed to have reduction in the severity to total absence of her symptoms. Through the later days prior to being ordered to be discharged, she was openly conversant and had a very good insight regarding her condition. She was euthymic. There were no reports of hallucinations, delusions and suicidal ideations since December 31,2011. She was appropriately reminded of her therapies and medications. She was ready for discharge by January 12, 2011. NCPs
  121. 121. One-year risk of psychiatric hospitalization and associated treatment costs in bipolar disorder treated with atypical antipsychotics: a retrospective claims database analysis BMC Psychiatry 2011
  122. 122. <ul><li>1-year risk of psychiatric hospitalization andtreatment costs in commercially insured patients with bipolar disorder </li></ul><ul><li>aripiprazole, ziprasidone, olanzapine, quetiapine or risperidone </li></ul><ul><li>followed for up to 12 months following the initial antipsychotic prescription </li></ul><ul><li>RESULTS : Compared to aripiprazole: </li></ul><ul><ul><li>ziprasidone, olanzapine and quetiapine – </li></ul></ul><ul><ul><ul><li>(hazard ratio 1.96, 1.55 and 1.56, respectively) </li></ul></ul></ul><ul><ul><li>risperidone – </li></ul></ul><ul><ul><ul><li>(hazard ratio 1.37) </li></ul></ul></ul>
  123. 123. Borderline Personality Disorder: Brain Differences Related to Disruptions in Cooperation in Relationships Science Update August 12, 2008
  124. 124. <ul><li>Different patterns of brain activity in people with borderline personality disorder </li></ul><ul><li>brain imaging and game theory ( a mathematical approach to studying social interactions) </li></ul><ul><li>borderline personality disorder - distorted sense of generally accepted social norms </li></ul><ul><li>Game (10-rounds): Each pair comprised a healthy “investor” and a “trustee,” who was either another healthy participant or a person with borderline personality disorder </li></ul><ul><li>55 with BPD, 38 healthy participants </li></ul>
  125. 125. <ul><li>bilateral anterior insula </li></ul><ul><li>In healthy participants, insula activity increased as offers or returned amounts decreased. </li></ul><ul><li>In participants with borderline personality disorder, insula activity increased only in response to low amounts they sent back to the investor; insula activity remained at an average level regardless of the amount offered to them by investors. </li></ul>
  126. 127. How Is Bipolar Borderline Personality Disorder Diagnosed? By Ben Paul
  127. 128. Fast Facts: <ul><li>Often seen in women </li></ul><ul><li>Can start early in life </li></ul><ul><li>Widespread instability of moods </li></ul><ul><li>often in and out of relationships but are often afraid; too afraid to be abandoned. </li></ul><ul><li>more controlling and may not want to let go in a relationship </li></ul><ul><li>indiscriminate in their sexual activities </li></ul><ul><li>love and hate relationship </li></ul><ul><li>look for acceptance from others to make them feel wanted and complete </li></ul>
  128. 129. Bipolar Borderline Personality Disorders <ul><li>The cause is said to be unknown however, environment and genetic factors are said to play a major role in its development. </li></ul><ul><ul><li>abused child and neglected or abandoned by parents or caregiver </li></ul></ul><ul><li>“ Unhappy earlier life or memory of abuse are often factors which will lead to making bad judgments as a grown-up when it comes to making life decisions like choosing life partner for example ” </li></ul>
  129. 130. Evaluating three treatments for borderline personality disorder Am J Psychiatry.  2007; 164(6):922-8
  130. 131. Borderline Personality Disorders <ul><li>OBJECTIVE: The authors examined three yearlong outpatient treatments for borderline personality disorder: </li></ul><ul><li>METHOD: Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to treatments and received medication when indicated. Prior to treatment and at 4-month intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment. </li></ul>
  131. 132. Borderline Personality Disorders <ul><li>The efficacy of 3 different psychotherapy treatments for borderline personality disorder were compared: </li></ul><ul><li>Dialectical behavioral therapy; </li></ul><ul><li>Transference-focused therapy; and </li></ul><ul><li>Supportive therapy. </li></ul>
  132. 133. Borderline Personality Disorders <ul><li>RESULTS: </li></ul><ul><li>transference-focused psychotherapy was associated with change in multiple constructs across six domains </li></ul><ul><li>dialectical behavior therapy and supportive treatment were associated with fewer changes. </li></ul><ul><li>Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault. </li></ul>
  133. 134. Borderline Personality Disorders <ul><li>CONCLUSIONS: </li></ul><ul><li>All treatments were effective to some extent, with transference-focused therapy the most successful in this particular trial. </li></ul>
  134. 135. <ul><li>(DSM-IV, p. 332) </li></ul><ul><li>A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). </li></ul><ul><li>During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: </li></ul><ul><ul><ul><li>inflated self-esteem or grandiosity </li></ul></ul></ul><ul><ul><ul><li>decreased need for sleep (e.g., feels rested after only 3 hours of sleep) </li></ul></ul></ul><ul><ul><ul><li>more talkative than usual or pressure to keep talking </li></ul></ul></ul><ul><ul><ul><li>flight of ideas or subjective experience that thoughts are racing </li></ul></ul></ul>DSM-IV CRITERIA Manic Episode
  135. 136. <ul><ul><ul><li>increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation </li></ul></ul></ul><ul><ul><ul><li>distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) </li></ul></ul></ul><ul><ul><ul><li>excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) </li></ul></ul></ul>
  136. 137. <ul><li>C. The symptoms do not meet criteria for a Mixed Episode. </li></ul><ul><li>D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. </li></ul><ul><li>E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism). </li></ul><ul><li>Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. </li></ul>
  137. 138. <ul><li>(DSM-IV, p. 338) </li></ul><ul><li>A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. </li></ul><ul><li>During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: </li></ul><ul><ul><ul><li>inflated self-esteem or grandiosity </li></ul></ul></ul><ul><ul><ul><li>decreased need for sleep (e.g., feels rested after only 3 hours of sleep) </li></ul></ul></ul><ul><ul><ul><li>more talkative than usual or pressure to keep talking </li></ul></ul></ul>DSM-IV CRITERIA Hypomanic Episode
  138. 139. <ul><ul><ul><li>flight of ideas or subjective experience that thoughts are racing </li></ul></ul></ul><ul><ul><ul><li>distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) </li></ul></ul></ul><ul><ul><ul><li>increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation </li></ul></ul></ul><ul><ul><ul><li>excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) </li></ul></ul></ul>DSM-IV CRITERIA Hypomanic Episode
  139. 140. <ul><li>C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. </li></ul><ul><li>D. The disturbance in mood and the change in functioning are observable by others. </li></ul><ul><li>E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. </li></ul><ul><li>F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). </li></ul><ul><li>Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder. </li></ul>DSM-IV CRITERIA Hypomanic Episode
  140. 141. DSM-IV-TR Diagnostic Criteria Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:     1. frantic efforts to avoid real or imagined abandonment. Note : Do not include suicidal or self-mutilating behavior covered in Criterion 5.   2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.    3. identity disturbance: markedly and persistently unstable self-image or sense of self.    4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note : Do not include suicidal or self-mutilating behavior covered in Criterion 5.   
  141. 142. DSM-IV-TR Diagnostic Criteria Borderline Personality Disorder   5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior    6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).    7. chronic feelings of emptiness    8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)    9. transient, stress-related paranoid ideation or severe dissociative symptoms
  142. 143. BIPOLAR MOOD DISORDER Mania <ul><ul><li>Increased social activity, sexually, socially and at work </li></ul></ul><ul><ul><li>Increased talkativeness </li></ul></ul><ul><ul><li>Flight of Ideas </li></ul></ul><ul><ul><li>Grandiosity </li></ul></ul><ul><ul><li>Decreased need for sleep </li></ul></ul><ul><ul><li>Distractibility </li></ul></ul><ul><ul><li>Poorly thought out involvement in projects and activities </li></ul></ul>Depression <ul><ul><li>Weight Change </li></ul></ul><ul><ul><li>Decreased sleep (insomnia/hypersomnia) </li></ul></ul><ul><ul><li>Decreased energy </li></ul></ul><ul><ul><li>Psychomotor retardation/agitation </li></ul></ul><ul><ul><li>Decreased interest in usual activities/ sexuality </li></ul></ul><ul><ul><li>Excessive self-reproach/guilt </li></ul></ul><ul><ul><li>Decreased ability to think or concentrate </li></ul></ul><ul><ul><li>Suicidal thoughts/action </li></ul></ul>