Assessment Subjective Verbalized nurse bakit ba ako nabubuhay?

Objective During college: - Has thoughts of hurting self like cutting or burning In 2011: - He resigned from work - Sad and less communicative - Attempted to slash wrist with a cutter - Took few tablets of valium Week 3: - withdrawn with sad affect

Diagnosis Risk for selfdirected violence

Scientific Rationale Behaviors in which an individual demonstrates that he/she can be physically, emotionally, or sexually harmful to self. Due to the decrease in Na, K-ATPase activity neuronal membranes become irritable needing fewer stimuli to provide cell firing. Hyperpolarizing functions of inhibitory neurotransmitter s are diminished. Prolonged decrease in Na, K-ATPase activity less stimulation needed to trigger depolarization. Neuron fires easily and action potential loses amplitude Decreased activity in calcium

Planning Short term: At the end of 4 hours of nursing intervention, the client will: not harm self verbalize feelings; express decreased anxiety and anger appropriately Verbalize understandin g of why behavior occurs. Identify precipitating factors in individual situation. Express realistic selfevaluation and increased sense of selfesteem. Participate in -

Intervention Determine whether client shows signs that will lead to harming self/suicide Determine history of suicide/ self harming attempts -

Rationale To prevent occurrence of harming oneself/ planned suicide To know if there is a pattern of occurrence to anticipate and intervene immediately To avoid further depression Showing concern can help establish trust from client making her cooperate in interventions Aids in discovering the root and cause of behavior to give optimal care and intervention

Evaluation Short term: At the end of 4 hours of nursing intervention, the client.. did not hurt/harm himself

and was able to: verbalize feelings; express decreased anxiety and anger appropriately Verbalize understandin g of why behavior occurs. Identify precipitating factors in individual situation. Express realistic selfevaluation and increased

Refrain from negatively criticizing Demonstrate concern about clients welfare

Facilitate discussion of factors or events that precipitated the suicidal thoughts

channels. Decreased neurotransmitter release resulting to depression manifested by suicidal behavior and violence.

care and meet own needs in an assertive manner. perform relaxation techniques

Remove dangerous items from the clients environment

to prevent provocation and implementatio n of suicide tendencies A calm external environment often helped to promote a relaxed internal state within the client and and may lessen agitation and prevent violence To prevent tendencies of injuring self

sense of selfesteem. Participate in care and meet own needs in an assertive manner. perform relaxation techniques

Long term: At the end of the shift, the client will: Demonstrate self-control as evidenced by relaxed posture, nonviolent behavior/verb alizations.

Reduce milieu noise and stimulation or accompany client to a calmer, quieter environment at early signs of anger,

Long term At the end of the shift, the client was able to: Demonstrate self-control as evidenced by relaxed posture, nonviolent behavior/verb alizations.

Place client in room with protective window coverings, as appropriate

Instruct client and significant other in signs, symptoms, and basic physiology of depression

To equip client and significant other with knowledge on what is it and how will it be mangaged.

Encourage to do deep breathing exercises, activity therapies such as music therapy, dance therapy, recreational therapy. Encourage client to continue seeking staff or family when experiencing frustration, stress, anxiety rather than waiting until the negative thoughts and feelings are out of control, which can lead to impulse tendencies of hurting self.

Helps client relax and divert clients attention

Staff and family can help the client prevent negative feelings from reaching destructive levels if they know the clients state in advance. Staff can also engage client in therapeutic activities/exer cises and can offer medications when necessary.

Instruct family that suicidal

To help the family know

risk increases for severely depressed clients as they begin to feel better Facilitate support of client by family and friends -

what are the things that can happen

To empower the client to feel the support to have a faster recovery Medications help control clients condition. Adherence can help client to be mentally stable. For manifestation s that cannot be managed/ done independently by the nurse.

Administer medications on time as orderedand promote compliance.

Refer client to psychiatrist, as needed.

Assessment Subjective: On admission, interviewed by relatives, - Sudden outburst of statements such as o Im rich, Im rich, I like Greenwich o Im running for presidency in 2014 Objective: March 2011, boyfriend of 6 months broke off with her: - Refused to go to work claiming to feel tired and exhausted. Eventually resigned from work. - For a month, became sad and less communicativ e April 2013, fathered passed

Diagnosis Ineffective Coping related to personal vulnerability secondary to bipolar I disorder

Scientific Rationale Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. Due to her Bipolar disorder, in presence of stressors, she either will be stimulated to be in hypomanic state manifested by elevated psychomotor agitation or on the other hand become depressed manifested by loss of interest, sadness and helplessness.

Planning Short term: After 4 hours of nursing intervention, client will be able to: -

Intervention Provide an atmosphere of acceptance. -

Rationale Establishing rapport is essential to a therapeutic relationship and supports the client in self-reflection. Recognizing problems and sharing feelings is best brought about in an atmosphere of warmth and trust. Factual information serves as a foundation for Client to explore feelings and alternative coping strategies. Stressed clients often misunderstan d facts and require frequent clarification so that

Evaluation Short term: After 4 hours of nursing intervention, client was able to: Verbalize how she handled stressful events and situations. Report decrease in negative feelings Identify effective and ineffective coping patterns

Verbalize how she handled stressful events and situations. Report decrease in negative feelings Identify effective and ineffective coping patterns

Long Term: Upon discharge, client will be able to, Effectively cope with stressors as manifested by increased ability to focus, verbalization of negative feelings and

Provide factual information concerning the diagnosis, treatment, and prognosis.

Long Term: Upon discharge, client was able to, Effectively cope with stressors as manifested by increased ability to focus, verbalization of negative feelings and

away: - Became restless and talkative - Constantly moving around - Unable to pay attention even for 5 minutes - Sleeps for 2-3 hours May 2013, department head given her memo regarding her absences from work. - Spending to much on expensive things

positive and realistic approach to stress.

appropriate conclusions can be drawn. Having valid information helps relieve stress. Arrange situations that encourage her autonomy. Give her as many opportunities as possible to make decisions/choi ces for herself. Explore with her previous methods of dealing with life problems. Enhances a sense of control, personal achievement, and self-esteem.

positive and realistic approach to stress.

Present and past coping status assists both Client and her husband in capitalizing on successful methods, identifying ineffective strategies, and developing new skills more appropriate to

Encourage verbalization of feelings, perceptions, and fears.

Encourage client to identify her own strengths and abilities.

the present situation. Also determines risk for inflicting selfharm. Open, nonthreatenin g discussions facilitate the identification of causative and contributing factors. Assists client to develop appropriate strategies for coping based on personal strengths and previous experiences. Improves selfconcept and sense of ability to manage stress. Helps client relax and divert minds attention

Instructed and demonstrated to do deep breathing exercises, activity therapies such as music

therapy, dance therapy, recreational therapy when experiencing stress. Discuss with concerned family and significant others how they can help. Family and friends are often willing but unsure how to help. Identifying specific strategies such as praise and encourageme nt during rehabilitation and healing will promote acceptance of change.