Pamantasan ng Lungsod ng Maynila

Intramuros, Manila
College of Nursing

BIPOLAR DISORDER

A CASE STUDY SUBMITTED TO PROF. JOAN M. OYANGOREN, RN, RM, MSN

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN
PSYCHIATRIC NURSING

BY:
GROUP 7
BSN III-2
Iledan, Mary Grace
Legaspi, Elijah
Minoria, Maria Clarissa
Pascual, Jilleane Carmela
Ponce, Faye Alexa
Ramos, Marii Saryrl

December 13, 2012

0

TABLE OF CONTENTS
Chapter 12
Introduction
Theoretical Framework
Personal Data
History of Present Illness
Past Personal History
Family History
Psychosocial History

Chapter 27
General Apperance and Behavior
Motor Behavior
Speech
Emotion
Form of Thought
Content of Thought
Perception
Other Cognitive Function
Defense Mechanisms

Chapter 312
Psychopathology
Nurse-Patient Interaction
Drug Study

Chapter 435
Prioritized Psychiatric Nursing Diagnoses
Psychotherapies Implemented

Chapter 537
Nursing Care Plans

CHAPTER 1
Introduction
Bipolar disorder or manic depressive disorder is a condition wherein an individual
experiences major shifts in moods, energy and way of thinking. They can be too
depressed and down for a while and then very happy in a second. These people are
usually very impulsive in making decisions. They can make a decision when theyre
depressed and regret it after. It is often characterized by alternate episodes of mania
and depression but they are more depressed than happy. It strikes early and can cause
lifelong disability. Reports show that it is chronically undertreated in many low-income
countries. The cause of bipolar disorder is unknown although studies have shown that it
can be genetic and it usually starts upon reaching the age of 15 to 25.
A study was conducted by the WHO (World Health Organization) to obtain
accurate cross-national information on the prevalence, correlates, and service patterns
of mental disorders. They found that the 1-year prevalence of bipolar disorder type I
was 0.4%, that of bipolar disorder type II was 0.3%, and that of sub threshold bipolar
disorder was 0.8%, for a total bipolar spectrum disorder annual prevalence of 1.5%.
In general, high-income countries had the highest prevalence of bipolar disease
and low-income countries had the lowest. The United States had the highest prevalence
of overall (4.4%) and annual (2.8%) disease, while India had the lowest (0.1% for both).
The mean ages at onset were 18 years for bipolar disorder type I, 20 years for bipolar
disorder type II, and 22 years for subthreshold bipolar disorder.
In our on setting, it is said to be five in every 100 Filipinos are suffering from
some form of depression, say mental health experts. Of them, a huge number have
what doctors call bipolar disorder or manic-depressive illness swinging from
depression to euphoria, unable to function normally, and in real danger of hurting
themselves and others.
Our chosen client, was diagnosed 10 years ago of a bipolar disorder. Classic
symptoms were manifested before admission such as lack of self-control,
impulsiveness, irritability etc. Her illness was said to be caused by Family problem. She
was oriented to three spheres but has a poor insight on her illness. Being hyperactive of
the client has been observed but does not harming the other patient on the ward. She
dressed appropriately according to age and sex. Grandiosity, flight of ideas and
confabulation were also elicited by here.

Theoretical Framework
Psychodynamic Theory
Professionals believed that bipolar illness was caused by psychological
difficulties. Developmental theorists have hypothesized that faulty family dynamics
during early life are responsible for manic behaviours in later life. According to this
view, the mother enjoys being the giver of life and resents autonomy. As the child
grows more independent, the mother becomes unhappy, so to please the mother,
the child becomes more dependent; that is, to gain affection, the child at an early
age learns to deny his or her own natural tendencies. The unnatural tension
between dependence and independence, and the inherent ambivalence in this
family environment, can be a causative factor in bipolar illness, according to this
view. Others have suggested that the polar events of childhood are so significant for
some people that an adult emotional counterpart to the emotional roller coaster
results. Many professionals believe that family dynamics plays an important role in
the genesis of manic-depressive illness.
Another psychodynamic hypothesis explains manic episodes as a defense
against or massive denial of depression. According to this view, manic-depressive
individuals go through life appearing to be independent and excessive to others, only
to be eventually blocked by someone who no longer tolerates being pushed, talked
to, or manipulated. When this happens, the manic individual might become
psychotic.
Psychobiologic Theory
Although some professionals still believe in the importance of psychological
factors, most are aware in the role of biology. Just as depression seems to be
caused by neurotransmitter deficiency, manic episodes also seem to be related to
excessive levels of norepinephrine and dopamine, an imbalance between
cholinergic and noradrenergic systems or a deficiency in serotonin. El-Mallakh
proposed that bipolar disorder, including both manic and depressive symptoms,
arises from ion disregulation. A more compelling view of altered biochemistry in
bipolar disorder has been advanced by Manji and Lenox. They outlined the evidence
for a breakdown in the complicated second-messenger systems of neurons. In the
multi-step second-messenger system, once a neurotransmitter binds to a receptor,
intracellular processes are triggered. Manji and Lenox show that in bipolar disorder,
there is greater activity than normal with G proteins and protein kinases and with
other steps in the second messenger system.
Personal Data
3

NAME:
Tessie T.
GENDER:
Female
AGE:
61
DATE OF BIRTH:
December 11, 1950
BIRTHPLACE:
Iloilo
OCCUPATION:
None
MARITAL STATUS:
Single
WEIGHT:
66 kg
HEIGHT:
154 cm
BODY MASS INDEX:
27.8 (Overweight)
RELIGION:
Roman Catholic
DATE AND TIME RECEIVED: 10:07 AM November 24, 2012
History of Present Illness
Patient is diagnosed for more than 10 years now. Last admission was March
2012. Lasting for 2 months and allegedly discharged improved. Home meds were
lithium carbonate and other unrecalled meds. Patient was allegedly on a regular follow
up check up c/o OPD basis. Last follow up October and has been compliant to her
medications. No behavioral changes noted since then, until..
1 week PTA, realtives noted increased in appetite and become argumentative
towards family members.
3 days PTA, patient suddenly became irritable, paranoid and violent and
continuously says papatayin ang ibang tao. During this time, patient also started
throwing things (garments and furniture) and water as well as to other people.
1 day PTA, there was an increased severity of violent behavior and harm to
others with episode of her throwing things to their housekeeper. Patient seemed
agitated with destructive behavior (nanunutok ng kutsilyo) hence she was brought at
PGH-ER and admitted.
Chief Complaint: Behavioral Changes
Impression
Axis I: Bipolar I disorder, most recent episode manic
Axis II: defer
Axis III: DM, dyslipidemia, hypertension
Axis IV: Poor primary care
Axis V: 21-30
Past Personal History
4

A. Pre-natal data
The patient was the 7th among 11 children. Beliefs are being sought after
by her mother such as it is prohibited to take a bath after a child was born.
Pre- natal consultation were done sometimes only the most important of
all. She was delivered normal at home by hilot. Her other siblings are
delivered normal as well.
B. Infancy
The patient was feed through breastfeeding only, without schedule, upon
demand by the child on an irregular basis. The child was seldomly cuddled
and the mother stayed with child only for a few hours in a day since she
was 7th and her mother has still many children to care for. She was
weaned at age1and years old. If the mother is not caring for the child,
her older sister is the one looking out for her. She was always nail biting
that time and characterized by finickiness to food and has frequent temper
tantrums. Her teeth was developed when she was months old. Her older
sister taught her how to walk and talk.
C. Anal Phase
Her mother was slightly fond of cleaning their environment too busy in her
work to provide the needs of her children. When eliminating, the child was
not scattering or playing with feces.
D. Oediphal Phase
According to the patient, she was playing with her neighborhood children
but when she was just laughing out with them, her father is always saying
Ang landi mo. From then on, she started to not gain more friends. Her
parents are not sleeping with her but just her brothers and sisters because
they have separate room.
E. School History
She started schooling when she was 6 years old. She was excited to go to
schooling because for her it will be a new environment. She adapts to
schoolmates well, she was playful and friendly during those times. She
was an average student and was never involved in any form of disciplinary
problems. But she was not able to finish her high school because of family
problem and financial constraints.
Family History
- Unremarkable

Psychosocial History
5

Support System
Before the patients hospitalization, she claims that she lives with her sister and
her sisters child. This serves as her primary support system. According to the
patient, her sister has a lot of business, including a barbershop, a soft drinks
dealership, and a garment shop. The businesses support their daily expenses
according to the client. The patient also claims that she has children who are in
Iloilo, one who is a doctor, one has a degree in education and the other one was not
able to finish studies, although she no longer expounded whether her child still
supports her.
Education
According to the patient, she began studying at the age of 6 years in Iloilo. She
was still able to recall her elementary school in Iloilo. She was able to adapt well in a
new environment and was able to mingle with new people. She can also remember
her High School although she finished only until the second year and stopped
studying due to financial constraints. Although she said that she and her mother
went to Manila when she was 4 and only returned only to Iloilo after her second year
in high school, the schools she mentioned were located in Iloilo.
Employment
The patient was previously employed in a garments shop somewhere in Pasay.
According to her, she was able to send her children to school because of this
employment. One of her children became a doctor, the other one finished education
and the second child unfortunately wasnt able to finish schooling. She left the
garments shop because she didnt like the people she was working with.
Substance Abuse
The patient has no documented history of substance abuse.
Medications
Because the client is both hypertensive and diabetic, she is taking Metoprolol to
manage her blood pressure and Metformin to manage her blood glucose levels. She
also takes lithium carbonate as a mood stabilizer and a form of management during
her manic episodes. She also takes a tablespoon of Virgin Coconut Oil daily.
6

Current Relationships
Before the patient was hospitalized, she lives with her sister and her sisters
children. She doesnt trust the individuals that she is living with because she fears
that they will take her money in her room while she is staying in the hospital. Before
hospitalization the patient also became violent to the helpers. With regards to her
other siblings, the patient thinks that her siblings have always been envious of her.
Nothing much was also discovered about her relationship with her children.

CHAPTER 2: Mental Status Examination

A. General Appearance and Behavior
Criteria
Hygiene
Grooming
Clothing
Body Appearance
Consciousness
Attention
Orientation

Day 1
Fair
Fairly kempt
Appropriate clothing
Average
Aware, awake, alert
Easy distractibility
Oriented to 3 spheres

Day 2
Fair
Kempt
Appropriate clothing
Average
Aware, awake, alert
Good attention span
Oriented to 3 spheres

Day 1
During nurse-patient interaction, the patient has a fair hygiene and is fairly kempt.
She is wearing appropriate clothing according to age and sex. She also has an average
weight. Patient was received conscious and awake and aware of her environment.
Patient is easily distracted and often greets and talks to every patient roaming around
during interview. She is oriented to the 3 spheres- person, place and time.
Day 2
Rapport and trust were established during the second day of interview. Patient
still has a fair hygiene. She is more presentable and has a kempt grooming during the
interview. She is also wearing appropriate clothing suited for her age and sex. She has
an average body appearance but she complained of being fat. Patient is still awake,
alert and aware of what is happening in her environment. As trust was gained, patient
became more attentive and focused on the interview. She had a good attention span.
When asked about the time, place and the interviewee, she answered correctly. She is
oriented to the 3 spheres.
7

B. Motor Behavior
Criteria
Behavior
Activities of Daily Living

Day 1
Normoactive
Independent

Day 2
Hyperactive
Independent

Day 1
Upon initial assessment during the interaction, patient exhibited a normoactive
behavior. She does not continue to wander around. She exhibited a proper and
appropriate behavior during the interview. Patient stated that she can carry out activities
of daily living on her own.
Day 2
During the second day of interaction, patient showed signs of a hyperactive
behavior. She carries and arranges the chairs and tables in the hallways. She roams
around the ward as well. Patient asked for a nap time. After fifteen minutes, patient was
awake and even looked for the nurse for another round of interview. Patient can perform
activities of daily living independently.
C. Speech
Criteria
Volume
Rate
Quality
Interview Behavior
Eye Contact

Day 1
Normal
Normal
Normal
Cooperative
Good eye contact

Day 2
Normal
Normal
Normal
Cooperative
Good eye contact

During the interaction, patient has a normal volume, rate and quality of speech. It
is not loud and only the nurse hears what the patient is talking about. The words are
pronounced clearly and audible. When asked, patient firsts waits for the question to be
finished before answering. The patient is cooperative and focused during the
interaction. Throughout the 2-day interview, patient maintained a good eye contact.
D. Emotion
Criteria
Mood

Day 1
Euthymic

Day 2
Euthymic
8

Affect

Appropriate

Appropriate

Patient stated that she is happy during the interview. She showed a euthymic
mood. Facial expressions and other non-verbal signs from the patient exhibited an
appropriate affect. How the patient feels during the interaction is evident on her
behavior.
E. Form of Thought
Criteria
Thought process

Day 1
Flight of ideas

Day 2
Flight of ideas

During the two-day nurse-patient interaction, patient has a flight of ideas. When
asked, the patient will answer the questions and will also add other answers that are not
related to the topic. Patient is coherent with the said topic but will eventually add other
stories as soon as she remembers some.

F. Content of Thought
Criteria
Thought content

Day 1
Grandeur, Religiously
preoccupied

Day 2
Grandeur

Day 1
Patient is religiously preoccupied. She is bothered about her religious activities
not being carried out because of hospitalization. She also has grandiose thoughts,
stating that she is the in the ward and most liked by the staff and patients. She inflated
her self-worth, knowledge and identity.
Day 2
During the nurse-patient interaction, patient still stated that she is the dealer of
softdrinks when in fact; her brother is the one who has that kind of business. Patient still
feels that she is wise and can handle any matters and concerns that will come in her
way. Patient still feels that the patients in the ward need her, based on her statement
that she also sells snacks in the ward.
G. Perception
9

Criteria
Perceptual disturbances

Day 1
No perceptual disturbances

Day 2
No perceptual disturbances

During the course of interview, patient was asked if she can hear or see anything
that cannot be heard or seen by anyone. Patient answered no. Assessing the patients
behavior, it is evident that she is not preoccupied with hallucinations and delusions or
anything that is beyond the normal.
H. Other Cognitive Function
Criteria
Disturbances of Memory
Levels of Memory
Intelligence
Insight
Judgment

Day 1
Confabulation
Intact recent and remote
memory
Good foundation of
knowledge
Poor
Good

Day 2
Confabulation
Intact recent and remote
memory
Good foundation of
knowledge
Fair
Good

During the two-day interview, patient showed a disturbance in memory such as

confabulation. She filled in the gaps from her past by telling imaginary experiences.
Some stories that she shared do not match from what is written in her chart. She told
the nurse during the interaction that she is the dealer of softdrinks before. When the
nurse asked the patients watcher, the latter stated that the patients brother is the
dealer. Patient has an intact recent and remote memory. She can still recall the food
that she took for lunch. The patient can also still recall some remote memories from her
past such as her jobs and workplaces. She has a good fund of knowledge. When asked
to do a simple mathematical computation, patient was able to perform it well. The
patient even stated that Math is one of her favorite subjects before. During the first day
of interaction, patient has a poor insight to illness. She stated that the reason she was in
the hospital is because the other patients misses her. When the second day of interview
came, patient developed a fair insight to illness. She stated that the reason why she
was admitted to the hospital is because she has a sakit sa damdamin. Patient is
compliant with her medications as well. The patient also has a good judgment when it
comes to emergency situations. She was given a situation and she was able to answer
it with good judgment.
I. Defense Mechanisms
Day 1

Day 2
10

Introjection
Rationalization
Projection
Denial

Projection
Rationalization

Day 1
During the nurse-patient interaction, the patient used defense mechanisms to
cope up with the underlying problems and concerns. She incorporated her values and
attitudes of a highly respected person as if it was her own. The patient talks to every
patient in the ward, interviewing and making friends with them. She is using Introjection
to help her cope up with the situation she is in. The patient is also utilizing
Rationalization as a means of escaping of proving that her feelings and behaviors are
justifiable. Patient stated that the she is being mistreated and locked up in her room
because her father and siblings are angry and jealous of her. The patient also blamed
her father for not having enough friends during her childhood days. She verbalized that
the reason why she did not gain lots of friends is because her father keeps on calling
her malandi everytime she laughs and hangs out with her neighbors. Through the
patients behavior and actions, she is also using denial. The patient has a poor insight of
her illness and she focuses on how the past had affected her instead of accepting the
current situation.
Day 2
On the second day of interview, the patient still used defense mechanisms for
coping up with the challenges in her life. The patient keeps shared how her father will
call her malandi everytime she haves fun and enjoys her time friends. She somewhat
blamed her father for not having a big circle of friends during gradeschool and
highschool. The patient also rationalized that she left her job because she does not like
her co-workers.

CHAPTER 3

11

12

13

14

Nurse-Patient Interaction
NURSE
Verbal
Magandang
hapon po sa
inyo Ate
Tessie!
Kumusta po
kayo?
Opo, kami po
ang nakaassign na
student
nurses at
magiging
kasama niyo
ngayong
araw.
PLM po,
Pamantasan
ng Lungsod
ng Maynila

Nonverbal
Offered
hand to
walk to
the bed

PATIENT
Verbal

Non-verbal

INFERENCE

NURSES
THOUGHTS AND
FEELINGS

Observable
Cues
Content:
introduces self
Mood: happy

Therapeutic
Techniques
Questioning

Content:
Acceptance of
company

Offering self,
giving
information

The patient is again

questioning or probing
about the nurses
background.

Giving
information

The patient has

knowledge about the
place where our
school is located and
shows awareness of
the topic we are
talking about.

Ito, okay
naman, kayo
ba ang nurse
ngayon?

Looks at
nurse and
walks with
her

Smiling,
assisting
client

Taga-saang
school kayo?

Looked at
nurse

Smiling
and glad

Malapit sa
Lyceum un
diba?

Smiling while Content: speaks

talking
out knowledge
and ideas

14

Mukhang
alam niyo ang
lugar na yun
ah.. malapit
lang po kami
doon.

Looks at
and leans
slightly
toward
patient

Oo, may
pamangkin kasi
ako nag-aaral
doon sa
Lyceum

Talking while
looking at
the nurse
and has
focus

Mukhang
malapit sayo
ung
pamangkin
mong iyon.
Nakikinig po
ako.

Looks at
ang leans
slightly
forward
the patient
Looking
into
patients
eyes

Hindi naman
naalala ko
lang.

Sige,
magtanong ka
pa, dito lang
ako nakaupo.

Ah, ganun po
ba. Alam niyo
po ba kung
anong oras
na ngayon?

Maintains Oo, 5:30 na.

eye
contact
and
moves
closer to
the patient

Content:
focuses on the
discussion

Making
observations

The patient recalled a

relative related to the
place we are talking
about.
The nurse is asking
patients views of the
meanings.

Normal facial Content: shares

expression,
relationship with
calm
the person

Interpreting

Opens discussion of
past events with the
person

Enthusiasm
and moves
closer to the
nurse

Content:
Speaks out
feelings

General leads

Normal
affect, calm

Content:
Reply
Mood: calm

Questioning

Asking permission to
the patient to know if
its okay for them to be
asked certain
questions. This can
also be the way to ask
for her cooperation
and the client shows
collaboration.
The patient is aware
of the time.
-Assessing for
orientation of time

15

Ano po ulit
ang buong
pangalan
ninyo?

Looking,
talking
while
smiling

Tessie Tortosa

Looked at
nurse,
responsive

Content:
-Assessing for
ability to know
her name

Saan po kayo
nakatira?

Smiles
and gains
eye
contact

Sa Navotas
ako nakatira at
Iloilo ang
probinsiya ko.

Smirks but
smile
afterwards

Content:
Assessing for
awareness of
home address

Ok po, eh
alam niyo po
ba kung
saang lugar
kayo ngayon.

gains eye
contact

Dito sa PGH
Ward 7. Ang
dami ngang
lamok eh, oh,
kinakagat kami,
nakabukas pa
nga ung
bintana. (Looks
at other patient
and talks to
her)
-Oh dito ka,
maupo ka,
makinig ka
samin.
Iniinterview
ako.
-Uy alam mo
ba, na-rape

Increased
speed in
speaking,
enthusiastic
in telling
stories

Content:
Observation
about other
patients
conditions

16

Questioning

The patient is attentive

and knows her full
name.
The patient is
responsive and knows
her current address.

Questioning

The patient is just

asked a question but
incorporated her other
ideas not related to
the topic being
questioned. The
patient is also showing
interest toward others.
-Assessing for
orientation of place

Paano niyo
naman po
nalaman?
Sino po ang
may sabi?

Salamat po
sa pag-alok,
kakatapos ko
lang din po
magmeryenda.
Mukhang
mahilig po
kayo kumain
ha.

yan. Huwag
kang maingay,
satin lang.
Kawawa nga
eh.
Inhales
Ayan, ung
deeply
isang pasyente
dito. Sobrang
tahimik niyan at
walang imik
pero mabait
yan. Gusto mo
ng korniks?
Kakakain ko
lang kanina,
snacks naman
tayo. Pinabili
ko ito sa
kapatid ko eh.
Smiles,
Marami akong
sees the
pagkain dito,
food being tingnan mo,
offered
puno yan. Sila
pa nga
nanghihingi
sakin ng pera,

Looks at the
patient
talking

Content: talks
about her diet
and other
peoples
obeservation

questioning

The patient again

incorporates other
ideas and shows that
she is fond of eating.

Eagerness
to answer,
talkative

Content:
Shows
grandiosity in
foods

Focusing

Content: Patient is
rationalizing and has
grandiose.
The patient is showing
grandiosity and feels
that she is blessed
with material things.

17

Mukhang
sinusuportaha
n at
inaalagaan
talaga kayo
ng kapamilya
niyo, sino po
ang nagbigay
niyan?

Smiles,
looks at
her things
in the bed
and table

Ung kapatid ko.

Dealer din kasi
ako ng
softdrinks sa
lugar namin.
Lahat ng mga
tindahan doon
kami ang
nagdedeliver.
Up and down
ang bahay
naming doon,
kasama ko ang
mga kapatid
kong babae,
mga intsik,
natatakot nga
ako dahil baka
hindi sarado
ung kwarto ko
ngayon baka
mawala ung
mga gamit ko,
may
magnanakaw
kasi doon.
Nawalan na ko
nun ng pera at
bag.

Looks at her
tale ang
fixed things
on her bed

Content:
Questioning,
Talks different
focusing
ideas and
physical
conditions in her
past
environment

18

Again, the client is

exhibiting grandiosity
about her business
and the house she is
currently living.
-There is flight of
ideas exchanging
topic from one to the
other.
Showing importance
of the significant
others is showed by
the nurse affirmed by
the patient.

Paano niyo
po nasabi na
nawala talaga
at may
kumukuha?
Nakita niyo
na po ba na
kinukuha ang
gamit niyo?
Ah tapos po?

Moves
closer for
clearer
perception
of patient

Nawala nga
eh, edi may
kumuha, basta
nawala, may
kumuha.

Justifies with
seriousness
in eyes

Content:
justification

Encouraging
description of
perceptions

-The client is firm with

her thoughts, not
incorporating others
opinions.
-asking for patients
views of their
situations.

Looks at
leans
slightly
toward the
client

Matandain ako,
alam ko na
kapag inilagay
ko doon lang
yun. Naiinis
nga ako eh.
May galit sila
sakin at inggit
pa.

Thinks
deeply and
looks around
the room

Content:
Feelings and
memory

Placing an
event in time or
sequence

Ganun po ba,
ano po sa
palagay niyo
at sila ay
nainggit at
nagalit sa
inyo?

Looks at
patient

Palabigay kasi Seems

ako at dealer
eager to
ako ng
answer
softdrinks sa
lugar namin,
bago ako
pumasok dito
nagpakulay din
ako ng buhok,
puro puti na eh,

Content:
Shows
generosity to
other people

Encouraging
evaluation,
focusing

Content: Patient is
firm with her thoughts
TT: The nurse is
encouraging
consideration of other
ideas and options but
the client is firm of her
memory and implies
feelings of hostility of
others toward herself.
The patient is
exhibiting grandiosity
and tangentiality.

19

tingnan mo,
buti ngayon ok
na.
Bagay nga po
sa inyo ung
kulay ng
buhok niyo.
Ano po pala
ang dahilan at
nandito po
kayo sa
ospital?
So ang ibig
po ninyong
sabihin ay
namimiss po
kayo ng mga
tao na
nandito sa
Ward 7?

Puts
hands in
the pocket

Namimiss ko
kasi ang mga
kasamahan ko
dito, namimiss
din nila ako.

A little smile
on her face

Content:
Shows feelings

Questioning

This concludes that

the patient has poor
insight to illness.

Maintains
eye
contact

Oo, ako kasi

ang mayor
doma dito, sabi
nila un,
palabigay daw
kasi ako ng
pagkain at
palabati sa
kanila.

Gladness on
her face

Content:
Grandiose
thoughts,
shares feelings

Restating

Totoo naman.
Sila may sabi
nun eh. May
mga utang pa

Laughing
while talking

Content:
Justification

Verbalizing the
implied

Noted here is
grandiosity and the
patient is rationalizing
her being grandiose.
The nurse is restating
or repeating the exact
words of patients to
remind them of what
they said, to let them
know that they are
heard.
The patient is aware
and answers to the
question relevantly.
There are additional

So ang sabi
Nods the
po nila ay
face and
palabigay
inhales
daw kasi kayo

20

ng pagkain at
palabati sa
kanila. Ano po
ang
nararamdama
n niyo?

Maam
Tessie,
maaaring
sinabi nila
sayo na kayo
ay mayor
doma, pero
alam niyo po
ba kung ano
un?
Bukod sa
namamahala,
siya rin ang
nasusunod sa
mga gawain.
Kayo po ba
ang
nasusunod

Maintains
eye
contact

Nods and
smiles

nga yan sakin,

ung watcher,
nagpabili ako
ng korniks,
binilan din niya
sarili niya, hindi
na ko
binayaran.
Mamaya,
sisingilin ko
yan.
Namamahala
yun diba?

Hindi naman.

ideas after her

answers.

Looks at
nurse

Content:
Asking for
clarification

Questioning

Patient wants
clarification and eager
to know more

Seems tired
but tries to
answer
honestly

Content:
Answers
question

Questioning

The nurse is giving

information and
induces clarification

21

dito sa
Gawain at iba
pa?
So maaari
nga po na
palabigay po
kayo at
palabati at
iyon ay kaiba
sa mayor
doma
Yun po siya,
siya nga pala
mukhang
mahilig kayo
sa korniks
ah...

Looking
into
patients
eyes

Ah, oo nga
baka nga.

Nods

Content:
Affirmation

Giving
information

The patient is
participating well.

Maintains
eye
contact
and
smiles

Smile also
and answers

Content:
Responsive

Interpreting ,
making
observation

The patient seemed

recalling past events
with an important
relative or person.

Importante po
yata ang
kaibigan
niyong iyon.

Gains eye
contact
move
closer to
the client

Oo, palagi ko
tong kinakain
lalo nung bata
pa ko
kasama ko ung
mga kaibigan
ko.
Sakto lang,
naaalala ko
lang siya, pero
bihira lang din
ang kaibigan
ko noon.

Sadness in
the face

Content:
Speaks out
feelings

Interpreting,
focusing

The client starts to

open up her childhood
memories
unconsciously. She
finally speaks out to
the nurse what she
relly feels

22

Ano naman
po ang
dahilan at
bihira lang
ang kaibigan
niyo noon?

Moved
closer to
patient

Ano po ang
nararamdama
n niyo nung
panahong
iyon?

Moved
closer,
inhales
deeply

Hindi kasi ako

pinapayagan
noon ng tatay
ko
makipaglaro,
kasi kapag
tumawa lang
ako kasama
ang mga
kaibigan ko,
sinasabihan na
ako ng
malandi. Bihira
lang din talaga
ung malapit sa
akin nung
elementary at
high school.
Siyempre
malungkot,
pero ok lang.
Hindi ko
naman
kailangan ng
maraming
kaibigan eh

Portrays
sadness and
grimacing

Content:
Speaks
experiences
mood: sad

The nurse is
The client seemed to
questioning,
have bad memories in
using openher childhood
ended questions
to achieve
relevance and
depth in
discussion.

Sadness in
the face,
leans
backward in
the seat

Content:
Verbalizes
feelings

Focusing

23

The patient is
rationalizing and
exhibiting denial.

Paano niyo
po nasabi na
hindi niyo po
kailangan?

Ano po ang
dahilan at
kinukulong
kayo?

Looks at
patient

Eh, nagagalit
kasi
yung tatay ko
at sinasabihan
ako palaging
malandi kapag
nakikipaglaro
lang at
nakikipagtawan
an kaya mas
mabuti nang
konti na lang.
May mga bata
rin kasing
mahilig
mang-away at
hindi ko rin sila
kailangan
marami naman
akong kapatid
na
nagmamahal
sa akin.
Moves
Nagseselos
closer for
sila sa akin.
clearer
Hinahayaan
perception lang nila ako
na mag-isa sa
loob ng kwarto

Grimace and
puts hands
at cross on
the chest

Content:
Expression of
feelings

Encouraging
evaluation,
questioning

The client is using

compensation,
covering up for a
weakness by
overemphasizing or
making up a desirable
trait.

Thinks
deeply and
looks around
the room

Content:
feelings

Focusing

Misconception of the
acts and attitudes
toward others. She
may be closed in a
room by her siblings
not due to jealousy but

24

at manood ng
TV.

Ano po ba
ang
nararamdama
n niyo nun?

Naiintindihan
ko po na
maaaring
masaya o
maiinis kayo.

Maintains
eye
contact
and
sincerity in
speaking

Holds the
patient
and taps
her
shoulders
side
May mga
Eye
naririnig po
contact
ba kayong iba with
o mga boses patient
maliban sa
naririnig natin
ngayon dito
sa paligid?

because of her
behavior

Masaya,
minsan naiinis
sa kanila,
hinahayaan ko
na nga lang
sila eh. Ewan
ko ba sa mga
taong iyon.
Buti naman at
naiintindihan
mo ako

Looks at the
floor

Content:
Willingness to
talk about the
topic

Encouraging
description of
perceptions

Different moods are

being portrayed.

Nodded
head

Content:
affirmation

There is now rapport

between patient and
nurse

Wala naman.

Turns head
on sides

Content:
Perceptual
disturbances

Empathy with
the patientrecognizing and
acknowledging
patients
feelings.
Questioning

25

Content: Denied
perceptual
disturbances
particularly the
auditory
hallucinations.
- Nurse is assessing
for the perceptual
disturbances

May mga
nakikita po ba
kayo na iba?

Moved
closer to
patient

Wala.

Turns head
on sides

Content:
Perceptual
disturbances

Questioning

Ano po ang
Maintains
nararamdama eye
n niyo
contact
ngayon?

Masaya
naman.

Answers
with smile

Content:
feelings

Encouraging
evaluation

Ano po ung
mga kinain
niyo kaninang
tanghali?

Kumain ako ng
pinadala sa
akin ng kapatid
ko, ung pork
steak at gulay,
nagmeryenda
din ako ng
biscuit. Saglit
lang kukunin ko
ung pineapple
juice, ok lang
ba ito kasama
ung gamot
kapag iinumin
ko mamaya?

Happy to
answer and
recall recent
past

Content:
Diet history

Questioning

Smiles

26

Denied perceptual
disturbances
particularly the visual
hallucinations.
-Nurse is assessing
for the perceptual
disturbances
She has consistent
mood since the
opening of the
conversation, and the
mood is congruent
with her affect.
The patient answers
questions immediately
at the initial of her
answer and
incorporates other
ideas and questions.
- Assessing for recent
past

Opo, ok lang
naman po
yan.

Ilan po pala
ang anak
ninyo?

Saglit lang ha,

hahaluin ko
muna, wala
akong bantay
ngayon eh,
ewan ko ba
kung nasaan.
(Pagkainom ng
bjuice),
malakas ako
uminom ng
tubig eh at
palagi akong
naihi.
Tatlo ang anak
ko. Isa doctor
na, ung isa,
hindi
nakatapos, at
ang bunso,
education ang
kinuha, lahat
sila nasa Iloilo.
Napagtapos ko
silang lahat sa
pag-aaral.

Patient seems to
have an increased
fluid intake and output
in relation to the side
effects of her
medications, lithium
carbonate.
Giving affirmation

Questioning

27

The patient recalls her

important someone in
her life.

Ah ganun po
ba, ano po
ung naging
trabaho niyo
at
nasuportahan
niyo ang tatlo
niyong anak?

Maintains
eye
contact,
puts arms
in the
chest

Kaya po pala.
Paano po
kung
nasunugan
kayo ng
bahay at
naiwan niyo
ang paborito
niyong damit,
at delikado
kapag babalik
ka pa,
babalikan
niyo pa po ba
damit niyo o
illigtas niyo
ang sarili
niyo?

Looks at
and leans
slightly
forward

Sa garments
ako
nagtatrabaho
noon sa pasay.
Dalawa ang
palapag doon
at ako ang
inspeksyon ng
mga garments.
Illigtas ko ang
sarili ko, baka
mapaso pa ako
doon. Ayoko ng
mainit.

Had a slight
smile on her
face

Content:
memories

Focusing

Grandiosity is noted
again. Gives relevant
answers to nurses
questions.

Face with
curiousness

Content:
Assess for
jugdment

Questioning

- Shows relevance in
the answers to
questions but the
reason is very minimal
of importance for
herself.
-Assessing for the
capability of her
judgment

28

Ask ko lang
po 2+6
equals?

Smiles
while
asking

8- Eight

Count using
her fingers.

Content:
Answer that is
relevant
Mood: happy
and enthusiastic
Content:
Expression of
personal
feelings

Questioning

The patient has

normal intellect.
Nurse is assessing for
intellect

Recognition

Aknowledging her own

capability
reinforcement is being
portrayed, giving
feedback on positive
behavior.

Ok po pala
Smiles
kayo sa math.

Oo naman, isa Smiles

yan sa favorite
subjects ko eh..

Hayaan niyo
po,
ipapractice
natin yan.

Smiles

Ok lang. Ano
pala yung mga
gamot na
iniinom ko?

Curiousity in
the face

Content:
Eagerness to
learn

Verbalizing the
implied

Shows slight interest.

The nurse is
encouraging her
strength.

Sige po,
sasabihin ko
sa inyo

Maintains
eye
contact

Sige lang

Looks at the
nurse

Content:
Affirmation

restating

Compliance is being
shown by the patient.

Ung una po,

ung lithium
carbonate,
makakatulong
poi yon sa
damdamin
niyo,
pangalawa ay

Eye
contact
with
patient

Ah ganun ba,
ang dami ko
palang gamut
pati umiinom
ako ng VCO
ung virgin
coconut oil,
ang dulas nga

Looks at the
nurse,
sitting,
slightly
distracted

Content:
Health teaching

Giving
information

The nurse is giving

information and health
teaching regarding her
medications.

29

yung
metoprolol,
para bumaba
ang blood
pressure
ninyo at ang
pangatlo ang
metformin
para sa
diabetes
ninyo at
maging
maayos ang
sugar levels
ninyo.
Ganun po
Smiles
talaga yung
VCO,
masanay na
po kayo,
bastat inumin
niyo po ung
mga gamut
ninyo para
mas gumaling
pa kayo at
siguradong
kapag ginawa
yun,

sa bibig.

Oo nga,
masunurin
naman ako eh
at umiinom ng
gamot.

Smiles and
feels proud

Content:
Health teaching
and
encouragement

30

Encouraging
and
reinforcement is
being done by
the nurse.
Patient
encourages
herself and
compliant with
what the nurse
is saying.

Appreciation for ones

self

maaaring
mas
makalabas
kayo ng
maaga bago
mgapasko at
magbirthday
niyo.
Oh sige po.
Babalik na po
ako sa room
namin.
Salamat po s
a pakikinig

Smiles
and
maintains
eye
contact

Ok, salamat.
Mamaya ulit.

Smiles na
dnods,
taking me
outside the
room

Affirmation and
appreciation

Giving
information

Termination of the
discussion. The
patient is compliant.

Drug Study
Drug name

Classification

Risperidone

Benzisoxazole
derivative

Mechanis
m of
Action
Blocks
dopamine
and 5-HT
receptors

Indication

Contraindicatio
ns

Side effects

-Monotherapy or
combination
therapy with
lithium or

-Contraindicated
in patients
hypersensitivity
to drug

CNS: fatigue,
depression,
nervousness,
abnormal thinking

31

Nursing Considerations
-Warn patients to avoid
activities that require
alertness until effects of
drug are known.

in the
brain

Lithium
carbonate

Alkali metal

valproate for 3week treatment

of acute manic
or mixed
episodes from
bipolar disorder
-Irritability
including
aggression, selfinjury, and
temper tantrums
associated with
an autistic
disorder

Probably
To prevent or
alters
control mania
chemical
transmitter
s in the
CNS,
possibly
by
interfering
with ionic
pump
mechanis
ms in
brain
cells, and
may
compete
with or

-Use cautiously
in patients with
prolonged QT
interval,
cerebrovascular
disease,
dehydration,
hypovolemia and
history of
seizures

CV: hypertension
GI: constipation
Metabolic: weight
gain
Musculoskeletal:
arthralgia, back
pain
Respiratory:
coughing
Skin: dry skin

-Warn patient to rise

slowly, avoid hot
showers.
-Advise patient to use
caution in hot weather to
prevent heatstroke.
-Tell patient to take drug
with or without food.
-Advise patient to avoid
alcohol during therapy.
-Life threatening
hyperglycemia may occur
in patients taking atypical
antipsychotics.

-Avoid using in
pregnant patient
unless benefits
outweigh risks.

CNS: headache,
fatigue, dizziness
CV: blurred vision
GI: vomiting,
anorexia, thirst
GU: polyuria,
Musculoskeletal:
weakness

-Check fluid intake and

output.
-Weigh patient daily;
check for edema or
sudden weight gain.
-Tell patient to take drug
with plenty of water to
minimize GI upset.
-Warn patient and
caregivers to expect
transient nausea, large
amounts of urine.
-Drug alters glucose
tolerance in diabetics.
Monitor glucose level
closely.

32

replace
sodium
ions.
Clonazepa
m

Benzodiazepin Acts by
e
facilitating
the effects
of the
inhibitory
neurotran
smitter
GABA.

-Panic
Disorders

--Contraindicated
in patients
hypersensitive to
benzodiazepine.
-Use cautiously
in elderly
patients. Drug
may accumulate
due to potential
decrease in
hepatic and
reanl function

CNS: slurred
speech,
CV: palpitations
EENT: abnormal
eye movements,
GI: nausea,
vomiting
Skin: rash

Amlodipine

Calcium
channel
blocker

-Hypertension

-Contraindicated
in patients
hypersensitive to
drug.

CNS: headache,
somnolence,
fatigue
CV: palpitations
GI: nausea,
Musculoskeletal:
muscle cramps

Inhibits
calcium
ion influx
across
cardiac
and
smoothmuscle
cells,
dilates
coronary
arteries
and
arterioles,

33

-Dont stop drug abruptly

because these may
worsen seizures.
-Assess elderly patients
response closely. Elderly
patients are more
sensitive to drugs CNS
effects.
-Advise patient to avoid
driving and other
hazardous activities that
requires mental alertness
until drugs CNS effects
are known.
-Monitor patient carefully.
-Monitor blood pressure.
-Caution patient to
continue taking drug,
even when he feels
better.

Metformin

Biguanide

and
decreases
blood
pressure
and
myocardia
l oxygen
demand.
Decrease
s hepatic
glucose
production
and
intestinal
absorption
of glucose
and
improves
insulin
sensitivity

-Adjunct to diet
and exercise in
type 2 diabetes
as monotherapy
or with a
sulfonyurea

-Contraindicated
in patients
hypersensitive to
drug.

34

CNS: headache
GI: diarrhea,
nausea and
vomiting

-Warn patient not to

consume excessive
alcohol during taking the
drug.
-Monitor patients glucose
level.
-Instruct patient about
nature of diabetes.

35

CHAPTER 4
Prioritized Psychiatric Nursing Diagnoses
1. Disturbed thought content
Disturbed thought content means that the client has ideas in her mind
different from what is reality. This is manifested by the patient since she said that she
is the mayor doma of the ward which is not true. This is the main priority nursing
diagnosis and this must be corrected. It is the priority since the main focus is mental
health which manipulates our activities of daily living.
2. Fatigue related to insomnia
Fatigue is an overwhelming sustained sense of exhaustion and decreased
capacity for physical and mental work at usual level. It is caused by consecutive
days of not sleeping in the right time and not getting the adequate and quality sleep
causing her to feel tired and restless during the day. It exacerbates physical and
mental work so it should be also addressed.
3. Altered Nutrition: Less than body requirements related to anorexia and
hyperactivity, as evidenced by lack of interest in food
Adequate nutrition plays an important role in healing and recovery. Altered
Nutrition: Less than body requirements refers to an intake of nutrients insufficient to
meet daily requirements because of inadequate food intake. An inadequate food
intake may be caused by inadequate knowledge about essential nutrients and a
balanced diet. It is also related to her childhood finickiness to food still adapted on
her current age. The major goals for this problem is to maintain or restore optimal
nutrition status, promote healthy nutritional practices and prevent complication
associated with malnutrition.
4. Impaired verbal communication related to disturbed thought content
Impaired verbal communication is the process where there is an addition or
subtraction of ideas with what is asked. it is also the over expression of thoughts
which sometimes the answers are not relevant to the question. Bipolar patients
manifest this kind of symptom most especially when they are in manic state.
Grandiosity and flight of ideas are some of the disturbances in verbal communication
to be corrected through appropriate nursing interventions.
5. Disturbed sleeping pattern related to hyperactivity
Disturbed sleeping pattern is also the most popular problem in regards with
bipolar patients. Bipolar patients are known to be on their hyper or hypo condition.
During the shift, the patient manifested a hyper state of condition, in this case, the
client wanted to do activities as much as he can, to the point that the patient has less
rest and more activities which is not in normal. 8 hours of sleep is required for the
individual to fulfill his sleep/rest pattern, during this time, the body has the time to
repair whatever is destroyed.
35

Psychotherapies Implemented
Art Therapy
Art therapy is a form of expressive therapy that uses art materials, such as
paints, chalk and markers. Art therapy combines traditional psychotherapeutic
theories and techniques with an understanding of the psychological aspects of the
creative process, especially the affective properties of the different art materials.
Although art therapists have generated many specific definitions of art therapy, most
of them fall into one of two general categories. The first involves a belief in the
inherent healing power of the creative process of art making. This view embraces
the idea that the process of making art is therapeutic; this process is sometimes
referred to as art as therapy. Art making is seen as an opportunity to express oneself
imaginatively, authentically, and spontaneously, an experience that, over time, can
lead to personal fulfillment, emotional reparation, and transformation.
The second definition of art therapy is based on the idea that art is a means of
symbolic communication. This approach, often referred to as art psychotherapy,
emphasizes the products-drawings, paintings, and other art expressions--as helpful
in communicating issues, emotions, and conflicts. The art image becomes significant
in enhancing verbal exchange between the person and the therapist and in
achieving insight; resolving conflicts; solving problems; and formulating new
perceptions that in turn lead to positive changes, growth, and healing. In reality, art
as therapy and art psychotherapy are used together in varying degrees. In other
words, both the idea that art making can be a healing process and that art products
communicate information relevant to therapy are important.
As a form of psychotherapy, art therapy often involves both the creation of art
and the discovery of its meaning. Individuals are encouraged to visualize, and then
create, the thoughts and emotions that they cannot talk about. For other people with
mental illness or disabilities, the creative process of art making becomes the
therapy. During the 20th century, art therapy was popular as a form of milieu therapy
at psychiatric institutions and was an important influence on the development of art
therapy in the United States. Milieu therapies focus on putting the patient in a
therapeutic social setting that provides opportunities to develop self-confidence and
interact with others in a positive way.
Objectives:
To assess patients emotions and thoughts.
To assess the patients ability on social interaction.

To help the patient in fostering self-expression, enhancing coping skills,

managing stress, and strengthening a sense of self.

36

37

CHAPTER 5
Nursing Care Plans
ASSESSME
NT
S: Ako ang
mayor doma
dito, marami
rin ang
nagsasabi
dahil
palabigay
ako ng
pagkain at
palabati, as
verbalized
by the
patient.
O:
- Receive
patient
roaming
around
- With
kempt
grooming
and

DIAGNOSIS
Disturbed
thought
content
related to
ideas of
grandiosity

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Mania
episodes

Within the shift,

the client must
be able to:
-Know reality
and verbalize
false ideas
-Have
clarification with
her current
situation and
illness
-Express feelings
and thought
-Identify
psychotherapy
activities

-Establish
trust
and rapport

- Trust and rapport

are important
factors in order to
gain patients
cooperation with
the management
of her sickness.

Goal met. The

patient was
able to know
reality and had
clarification
with her
current
situation.

Increase
number of
preconceptio
ns

grandiosity

Disturbed
thought
content

-Initiate
therapeutic
interaction

-Encourage
expression
37

- Therapeutic
communication
will help the client
to feel
comfortable with
the care provider.
It will help the
patient to explore
and share his own
thoughts and
feelings without
difficulty and
feeling anxious.

-Verbalizing and

appropriate
clothing
Cooperative
during
interview
and has
good eye
contact
- Has good
attention
span
- Oriented to
time, place
and person
Hyperactive,
independent
on activities
on daily
living
- Has
normal
volume,
quality and
rate of
speech
- Has
euthymic

feelings
expansion
thoughts

and expressing feelings

of will help the client to
identify his own
problem and needs
and let the patient
cooperate with the
therapeutic
management
-Present reality
and explain her
Presenting to reality
current situation
and surroundings
will help the client to
avoid further
disturbances in the
thought processes
-Facilitate
psychotherapy
Activities are one
activities
of the ways to
explore the clients
problems and
worries. In that way,
the care provider
will be able to
formulate
appropriate
intervention to solve
the clients anxiety.
-Reinforce
compliance
to
-Compliance to
meals
and
38

mood and
appropriate
affect
- Has
relevant
responses
- Denied
perceptual
disturbances
- With flight
of ideas
- With
grandiosity
noted
- Has good
foundation of
knowledge
- Has intact
recent and
remote
memory
Confabulatio
n is noted
- Has good
judgment
and fair
insight to
illness

medications

39

meals and
medications will
help the client for
fast recovery.

40

ASSESMENT
S: Oo, nagddiet
na nga ako eh,
sobrang taba ko
na rin. Biscuit na
lang kakainin ko
mamaya. Wala rin
akong gana
kumain., as
verbalized by the
patient.
O:
-Holds a biscuit
-Decreased
excitement in
eating foods
-Lack of interest in
foods
-hyperactivity
- With kempt
grooming and
appropriate
clothing
- Cooperative
during interview
and has good
eye contact
- Has good
attention span
- Oriented to
time, place and
person

DIAGNOSIS
Altered
Nutrition:
Less than
body
requirements
related to
anorexia and
hyperactivity,
as
evidenced
by lack of
interest in
food

INFERENCE
Mania
episodes
Increase
energy
Hyperactivity
Loss of
appetite

PLANNING
INTERVENTION
Within the shift, the
-Establish
client must be able
trust
and
to:
rapport
-know the
importance of eating
right amount of
nutritious foods at
the right time
-Increase interest in
foods
-Remain free of
manic episodes
-Initiate
therapeutic
interaction

RATIONALE
- Trust and rapport
are important
factors in order to
gain patients
cooperation with
the management
of her sickness.
- Therapeutic
communication
will help the client
to feel
comfortable with
the care provider.
It will help the
patient to explore
and share his own
thoughts and
feelings without
difficulty and
feeling anxious.
-Verbalizing and
expressing feelings
will help the client to
identify his own
problem and needs
and let the patient
cooperate with the
therapeutic
management

-Encourage
41

EVALUATION
Goal partially
met. The
patient ate her
dinner but only
for a small
amount.

- Hyperactive,
independent on
activities on
daily living
- Has normal
volume, quality
and rate of
speech
- Has euthymic
mood and
appropriate
affect
- Has relevant
responses
- Denied
perceptual
disturbances
- With flight of
ideas
- With
grandiosity
noted
- Has good
foundation of
knowledge
- Has intact
recent and
remote memory
- Confabulation
is noted
- Has good
judgment and
fair insight to

verbalization
of feelings
and
expansion of
thoughts.

-Eating nutritious
foods et the right
time will aid and
enhance their fast
recovery and
thinking skills.
-Reduces fatigue,
maximizes energy
available for work of
eating.

-Explain the
importance of
eating right
amount of
nutritious
foods at the
right time.
-Offer rest
periods
before meals.

--Reinforce
compliance to
meals
and
medications

42

-Compliance to
meals and
medications will
help the client for
fast recovery.

illness
ASSESMENT

DIAGNOSIS

S: Matutulog
Fatigue
muna ako medyo related to
insomnia
napapagod ako
ngayon wala kasi
akong tulog
kagabi konti lang,
as verbalized by
the patient.
O:
- increase in rest
requirements
-perceived need
for additional
energy
- With kempt
grooming and
appropriate
clothing
- Cooperative
during interview
and has good
eye contact
- Has good
attention span
- Oriented to
time, place and

INFERENCE
Mania
episodes
Increase
energy
Hyperactivity
Fatigue

PLANNING
Within the shift, the
client must be able
to:
-report improved
sense of energy
- Identify basis of
fatigue and
individual areas of
control.
- participate in
desired activities at
level of ability.

INTERVENTI
ON
-Establish
trust
and
rapport

-Initiate
therapeutic
interaction

-Encourage
expression
feelings and
expansion of
thoughts

43

RATIONALE

EVALUATION

- Trust and rapport

are important
factors in order to
gain patients
cooperation with
the management
of her sickness.

Goal partially
met. The
patient
identified basis
of fatigue and
areas of
control and
start to
participate in
activities at
level of ability.

- Therapeutic
communication
will help the client
to feel
comfortable with
the care provider.
It will help the
patient to explore
and share his own
thoughts and
feelings without
difficulty and
feeling anxious.
-Verbalizing and
expressing feelings
will help the client to
identify his own

person
Hyperactive,
independent on
activities on
daily living
Has normal
volume, quality
and rate of
speech
Has euthymic
mood and
appropriate
affect
Has relevant
responses
Denied
perceptual
disturbances
With flight of
ideas
With
grandiosity
noted
Has good
foundation of
knowledge
Has intact
recent and
remote memory

- Identify
presence of
physical
and/or
psychological
conditions
-Provide for
quiet
environment;3.
cool room,
decreased
sensory
stimuli,
soothing
colors, quiet
music.
-Review
medication
regimen/use.
4.

44

problem and needs

and let the patient
cooperate with the
therapeutic
management
-These can
exacerbate fatigue.

Reduces stimuli
that may
aggravate
agitation,
hyperactivity,
and insomnia.

- Certain
medications,
including
prescription are

- Confabulation
is noted
- Has good
judgment and
fair insight to
illness

1.

Assess
psychologi
cal and
personalit
y factors
that may
affect
reports of
fatigue
level.

known to cause
and/or
exacerbate
fatigue.

-Some
characteristic
and personalities
of a person can
affect ones
activity.

2.
-Reinforce
compliance to
meals and
medications

45

- Compliance to
meals and
medications will
help the client for
fast recovery.

ASSESSMENT
Ung kapatid ko. Dealer
din kasi ako ng
softdrinks sa lugar
namin. Lahat ng mga
tindahan doon kami
ang nagdedeliver. Up
and down ang bahay
naming doon, kasama
ko ang mga kapatid
kong babae, mga intsik,
natatakot nga ako dahil
baka hindi sarado ung
kwarto ko ngayon baka
mawala ung mga gamit
ko, may magnanakaw
kasi doon. Nawalan na
ko nun ng pera at bag.
As verbalized by the
client

DIAGNOSIS
Impaired verbal
communication
related to
disturbed
thought content

INFERENCE
Mania
episodes

GOAL
INTERVENTION
Within 8
-Establish
trust
hours of
and rapport with
nursing
the patient
Increase
intervention,
energy
the client will
be able to
Hyperactivity
have an
organized
Increase
and relevant
number of
verbal
preconceptions communicatio
n as
Flight of ideas
manifested
- Render
by
therapeutic
Impaired verbal - (-) flight of
communication
communication ideas
- (-)
confabulation

O:
- Receive patient
roaming around
- With kempt
grooming and
appropriate clothing
- Cooperative during
interview and has
good eye contact
- Has good attention
span

RATIONALE
- Trust and
rapport are
important
factors in order
to gain
patients
cooperation
with the
management
of her
sickness.
- Therapeutic
communication
will help the
client to feel
comfortable
with the care
provider. It will
help the
patient to
explore and
share his own
thoughts and
feelings
without
difficulty and
feeling
anxious.
- Verbalizing

46

EVALUATION
Within 8 hours
of nursing
intervention,
goal partially
met, the client
had organized
and relevant
verbal
communicatio
n- (-)
confabulation

- Oriented to time,
place and person
- Hyperactive,
independent on
activities on daily
living
- Has normal volume,
quality and rate of
speech
- Has euthymic mood
and appropriate
affect
- Has relevant
responses
- Denied perceptual
disturbances
- With flight of ideas
- With grandiosity
noted
- Has good foundation
of knowledge
- Has intact recent
and remote memory
- Confabulation is
noted
- Has good judgment
and fair insight to
illness

- Encourage
express
verbalized
feelings.

to
and

and
expressing
feelings will
help the client
to identify his
own problem
and needs and
let the patient
cooperate with
the therapeutic
management

-Activities are
one
of the ways to
- Encourage
to explore the
participate
in clients problems
selected
group and worries. In
that way, the
activities
care provider will
be able to
formulate
appropriate
intervention to
solve the clients
anxiety.
-Presenting to
reality and
surroundings will
help the client to
- Present to reality avoid further
47

and surroundings disturbances in

frequently
the thought
processes
-Support and
empathy will
make the client
feel secured, in
- Offer support and that case, the
patient will trust
empathy
the care
provider. Trust
and rapport will
help the nurse to
do his medical
management
with the client
with ease.
- Monitoring
behaviour and
whereabouts to
avoid any
suicidal thoughts
- Monitor behavior and any
accidents.
and
whereabouts.
-Compliance to
meals and
medications will
help the client for
fast recovery.
- Ensured
compliance
to
48

meals
and
medications

ASSESSMENT
S: Hindi ako masyado
nakakatulog agad,
siguro mga limang oras
lang ang tulog ko sa
isang araw. Kapag
pinapatay ung ilaw,
matagal ako bago
makatulog. gusto ko
lang maglakad pa at
makipag-usap kaso
madilim na, kaya
nakahiga na lang ako,
as verbalized by the
patient.

DIAGNOSIS
Disturbed
sleeping
pattern
related to
hyperactivity

INFERENCE
GOAL
Mania
Within
8
episodes
hours
of
nursing
Increase
intervention,
energy
the client will
be able to
Hyperactivity have
an
improvement
Decrease
in sleeping
time to sleep pattern
or
feel rested.
Disturbed
- Report of
sleeping
feeling
pattern
rested.

O:
- Receive patient
roaming around
- With kempt
grooming and
appropriate clothing
- Cooperative during
interview and has

INTERVENTION
- Establish trust
and rapport

- Initiate
therapeutic
communication

- Encourage
expression of
feelings and
49

RATIONALE
- Trust and rapport
are important
factors in order to
gain patients
cooperation with
the management
of her sickness.

EVALUATION
Within 8 hours
of nursing
intervention,
the client
reported that
she feel
rested.
-Ok naman
- Therapeutic
na,
communication
nakapahinga
will help the client pahinga
to feel comfortable naman ako
with the care
kahit kaunti,
provider. It will
as verbalized
help the patient to by the patient.
explore and share
his own thoughts
and feelings
without difficulty
and feeling
anxious.
- Verbalizing and
expressing

good eye contact

Has good attention
span
Oriented to time,
place and person
Hyperactive,
independent on
activities on daily
living
Has normal volume,
quality and rate of
speech
Has euthymic mood
and appropriate
affect
Has relevant
responses
Denied perceptual
disturbances
With flight of ideas
With grandiosity
noted
Has good
foundation of
knowledge
Has intact recent
and remote memory
Confabulation is
noted

expansion of
thoughts

- Set limitation
with daytime
group activities.

feelings will help

the client to
identify his own
problem and
needs and let the
patient cooperate
with the
therapeutic
management
- Presenting to
reality and
surrounding will help
the client to avoid
further disturbances
in the thought
processes. It will
also help the patient
to focus and
concentrate to
identify her existing
problem and
cooperate with the
management of it.

- Discuss with
the client the
importance of

- Setting limits with

daytime activities
promotes
relaxation and
time to sleep.

- Present to
reality

50

- Has good judgment

and fair insight to
illness

avoiding heavy
meals and
caffeinated
drinks with the
management of
her disturbed
sleeping
pattern
- Reinforce
compliance to
medications

- Gastric digestion
and stimulation
from caffeine will
result in difficulty
from falling
asleep.

- Compliance to
medications will
help the client for
fast development
and recovery.

51