1

I. Introduction

Whatever happened to Rizal’s famous quote “The youth is the hope of the

nation” when a large percentage of the youth today are into intoxicating drugs and

substances?

These “future leaders” have indulged themselves into vices that are slowly

killing them and destroying their bright future, the country’s bright future. Through

sniffing and injecting cocaine the enjoyed a few minutes of ecstasy but unknowingly

they have let in a poison run through their veins destroying them from the inside. By

the time they realize (if ever they do) what’s happening, it is usually too late to repair

the damage done.

This is a case of twenty-three year old Ms. Esmeralda Gabinete, a resident of

Toledo City, Cebu. who, like the youths mentioned above, got herself into an

addictive vice like sniffing cocaine and injecting it into her own vein. She’s been

using it for nearly five years, realized last June that it wasn’t really doing her any

good, stopped, made a narrow escape from the cocaine’s deadly consequences but

otherwise suffered from its common withdrawal effect: psychosis.

A substance-induced psychotic disorder, by definition, is directly caused by

the effects of drugs including alcohol, medications and toxin. Psychotic symptoms

can result from intoxication on alcohol, amphetamines, cocaine and inhalants or as a

result of withdrawal from the mentioned substances.

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The disorder is categorized in two ways. First, it is subtyped based on whether

the prominent feature is delusion or hallucination. Hallucinations are seeing, hearing,

feeling, tasting or smelling things that are not there and delusions are fixed, false

beliefs. Second, it is subtyped based on whether it began during intoxication on a

substance or during withdrawal from a substance. A substance-induced psychotic

disorder that begins during substance use can last as long as the drug is used while a

psychosis that begins during withdrawal may first manifest up to four weeks after an

individual stops using the drug.

April Mechelle Tecson’s case is an interesting and controversial one.

Interesting in a sense that the student nurse is about the client’s age and it brings up

the possibility of finding an answer to the question: What could possibly have lead

those youths to bring about their own destruction? Controversial in a way because it

involves a prominent issue such as drug addiction and gives rise to questions such as:

What is the government doing to control these stuff and why are drug dens

( Kamputhaw is a famous one), even though everybody knows where they are, still

impregnable to authorities?

This case study aims to shed light on, as much as possible, all of the factors

that have lead to April Mechelle Tecson’s current state of health.

As her student nurse and as someone who has sentiments over a co-youth who

have gone astray, the author seeks to delve more on here case and find means to help

her and her significant others deal with the disorder substance-induced psychosis.
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II. Objectives

General Objectives:

This case study aims to help the student nurse in effectively providing

holistic caring care for a patient suffering from bipolar I disorder. It also aims to

aid the patient in coping with life situations, and incorporating it into her

reorientation to reality and activities of daily living for her optimum level of

functioning.

Specific objectives:

After 2 weeks of providing holistic caring care and facilitating student

nurse-patient interaction, the student will be able to:

1. perform a thorough assessment of an adolescent in her present

condition, and discuss the physical, social and cognitive characteristics

of an adolescent,

2. establish rapport and interact with the patient at the patient’s own

level and taking into consideration her present condition

3. identify the signs and symptoms presented by the patient in

relation to the disease process

4. implement a comprehensive plan of care for the patient with

substance-induced psychotic disorder, and

5. Evaluate the interventions provided in the given span of time for

efficiency and effectiveness.

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After 2 weeks of receiving holistic caring care, and participating in student

nurse-client interaction, the client and her significant others will be able to:

1. establish trust towards the student nurse

2. cooperate in procedures performed to the client for management

and treatment, such as adhering to the medication regimen,

3. participate with the student nurse in activities aimed at the patient’s

holistic well being, such s in art therapy and morning stretching

exercises,

4. manifest signs of reorientation to reality, and

5. terminate the therapeutic student nurse-client interaction at the end

of the given span of time

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III. Nursing Assessment

1. Personal History

1.1 Patient’s profile

Name: Tecson, April Mechelle Marson

Age: 23 years old

Sex: Female

Civil status: Married

Religion: Roman Catholic

Date of admission: June 8, 20010; 9:00 pm

Room No.: XII

Complaint: “nang hagis sa iyang bana, nga iyang patyon”, as verbalized

by mother-in-law

Impression/Diagnosis: Bipolar I disorder; most recent episode manic with

psychotic features

Physician: Dr. Yazar

1.2 Family and Individual information, social and health history

April Mechelle Tecson, 20-year old and single, was admitted by her

father, Ariel Tecson at Vicente Sotto Memorial Medical Center Psychiatry

ward at around nine in the evening. Client belongs to a low socioeconomic

class family and is the eldest among three siblings. She is a known alcoholic
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and cocaine abuser and a cigarette smoker. Hours prior to admission, client

was seen running after a pregnant neighbor with a knife in her hand.

Client was formerly enrolled at Abellana High School but stopped when

she reached second year high school. She was known to have started using

“shabu” injectables when she was fifteen years old. According to her mother,

Mrs. Rosalie Tecson, client was noticed to have stopped taking the said the

said drug last June and that’s when she started exhibiting the positive

symptoms such as talking and laughing by herself. When confronted that she

was acting weird, client responded angrily saying: “Ako man hinuoy praning!

Di ko praning! Basin ikaw!”.

Client’s family has a history of addiction and psychosis. Her mother’s

brother was also addicted to marijuana and was admitted at VSMMC

Psychiatry ward last 1980. Her father’s sister have had postpartum psychosis

last 1989 which was known to be recurrent. She already got well but the

condition returned last 1994. Factors thought to have influenced remission

include the fact that she was a battered wife and her husband was always

abroad and she was left with the responsibility of taking care of their only son

who has cerebral palsy.

Client’s medical history showed that client was admitted at Southern

Island when she was still days old and was diagnosed to have had meningitis.

Her mother expressed that it was probably due to the fact that April was

delivered not in the hospital but in their house. Mrs. Tecson gave birth with
 7

the aide of a “manghihilot/mananabang” who follows certain beliefs/odd

beliefs like having the baby taste her first feces as a form of “sumpa” against

evil spirits.

When April Mechelle was fourteen years old, she was admitted by her

boyfriend at North General Hospital due to massive bleeding. She was

diagnosed to have uterine laceration.

According to her mother, April Mechelle has only one bestfriend that

she knows of. Her name was “Ilang” and April shares with her all her

problems. Ilang was close to April’s mother so she can tell her what was

going on with April. However, Ilang got married and transferred residence so

April lost contact with her. Since then, Mrs. Rosalie Tecson was not able to

get information regarding the goings on in her daughter’s life because April

seldom talks to her about her feelings and concerns.

Upon admission, client was time, person and place oriented, has an

intact short and long term memory, with poor concentration and exhibited

circumstantiality. She is currently prescribed Haloperidol 20 mg. ½ tab OD,

Biperiden 2 mg. 1 tab OD and chlorpromazine 100 mg. 1 tab OD at hour of

sleep. Client is for homicidal and suicidal precaution.

1.3 Level of Growth and Development

1.3.1 Normal Development at stage of adolescence (12-20 years old)

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The rate of a person’s growth and development is highly individual;

however, the sequence of growth and development is predictable. Gowth

and development are commonly thought of as having five major

components: physiologic, psychosocial, cognitive, moral and spiritual.

On this case, the client, Ms. April Mechelle Tecson, 20 years old, is

on the stage of adolescence. She is specifically in the middle of being an

adolescent and a young adult because according to Fundamentals of

Nursing by Barbara Kozier, and adolescent’s age ranges from twelve up to

twenty years old, while a young adult is twenty to forty years old.

An adolescent’s self concept changes with biologic development.

Values are tested, physical growth accelerates and stress increases,

especially in the face of conflicts. Significant others should assist

adolescents to develop their coping behaviors.

Physiologic Development

Physical changes occur rapidly in adolescence. Sexual maturation

occurs with the development of primary and secondary sexual

characteristics. Four main focuses of the physical changes are:

1. increased growth rate of skeleton, muscle and viscera

2. sex-specific changes, such as changes in shoulder and hip

width

3. alteration in distribution of muscle and fat

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4. development of the reproductive system and secondary sex

characteristics

Wide variation exists in the timing of physical changes associated

with puberty between sexes and within the same sex. Girls tend to begin

their physical changes earlier than boys. April have had her menses at the

age of 11.

Height and weight increases usually occur during the prepubertal

growth spurt. The growth spurt for girls generally begins between 8-14

years of age. Height increases 2-6 inches and weight increases by 15-55

pounds. The final 20 % to 25% of adult height and 50% of adult weight is

gained during this time period.

The client’s build is within the normal range. The client’s height is

5’1’’ and weight is 120 lbs.

Developmental Task Theories

According to Robert Havighurst, growth and development occurs

during 6 stages, each associated with 6-10 tasks to be learned.

April is in the stage of adolescence and the tasks are as follows:

 achieving emotional independence from parents and other

adults

 achieving assurance of economic independence

 selecting and preparing for an occupation

 preparing for marriage and family life

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 developing intellectual skills and concepts necessary for

civic competence

 desiring and achieving socially responsible behavior

 acquiring a set of values and ethical system as a guide to

behavior

Psychosocial

According to Sigmund Freud

Client is at genital stage wherein energy is directed towards full

sexual maturity and function and development of skills needed to cope

with the environment. Separation from parents, achievement of

independence and decision making are encouraged.

According to Erik Erickson

Erickson envisions life as a sequence of levels of achievement. Each

stage signals a task that must be achieved. The resolution of the task can

either be complete, partial or unsuccessful. April is at the adolescence

stage ( 12-20 y.o.) with a central task identity vs. role confusion. A

coherent sense of self and plans to actualize one’s abilities are indicators

of a positive resolution for this stage.

According to Roger Gould

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Gould believes that transformation is a central theme during

adulthood. 20’s is the time when a person assumes new roles. April is at

stage 2 ( 18-22 y.o.). According to Gould, at this stage, although the

individuals have established autonomy, they feel it is in jeopardy. They

feel they could be pulled back into their families.

Cognitive

According to Jean Piaget

Cognitive development for Piaget is an orderly, sequential process in

which a variety of new experiences must exist before intellectual abilities

can develop. There are five major phases and April, based on her age, is

supposed to be at the formal operations phase where rational thinking and

deductive and futuristic reasoning is expected. However, her current

condition does not enable the student nurse to assess fully her cognitive

abilities at the absence of her psychosis.

Moral Development

According to Laurence Kohlberg

There are three levels and six stages. April is at the conventional

stage where the person is concerned with maintaining expectations and

rules of the family, group, nation, or society. There is a sense of guilt that

affects behavior. She is at the stage 3: Interpersonal Concordance

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Orientation where decisions and behavior are based on concerns about

other’s reactions, the person wants others’ approval or a reward.

April, based on her significant other’s account, was at this stage

when her addiction developed and is still at the stage now.

According to Carol Gilligan

The student nurse has difficulty pinpointing at what specific stage

the client is due to the limited time of contact with the client. Stage 3:

caring for self and others prevailed. The concept of responsibility now

involves responsibility for self and others.

Spiritual Development

According to James Fowler

James Fowler describes the development of faith as a force that gives

meaning to a person’s life. Ideally, April is at the synthetic-conventional is

structured by the expectations and judgment of other; interpersonal focus.

According to Wersterhoff

April is at the experience faith stage which is a stage not normally

for young adult based on Westerhoff’s theory. At this stage, client

experiences faith through interaction with others who are living particular

faith tradition.

1.3.2 The ill person at particular stage of patient

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Developmental Task theory

Based on the student nurse’s assessment on the client, April has

failed to achieve the last 7 tasks, starting from achieving emotional

independence from the parent and other adults. Even though April has

gone emotionally distant from her parents, it is not a sign of being

emotionally mature and independent. It is just another way diverting her

emotional needs and conflicts because she couldn’t reach them.

There has been no assurance of economic independence all

throughout her childhood and adolescent years because the family is

struggling financially. Selecting and preparing for an occupation and

married life wasn’t on her list of priorities for the past years because she

got hooked with an illegal substance and all she could think of were means

of supporting her vices.

April stopped going to school at the age of 15 and didn’t go through

any livelihood trainings or seminars so skills and concepts necessary for

civic competence weren’t met either. A socially responsible behavior isn’t

observable considering that what she had done and what she had gotten

herself hooked to is a menace to the society and one of the major reasons

why the crime rate is rapidly escalating. Values and ethical system are

vague yet and self-awareness and value clarification are ought to be

realized.

Psychosocial development
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According to Sigmund Freud

Based on the account of the client’s significant other, client was

found out to be orally fixated. Her mother mentioned about difficulty

providing her5 eldest daughter with the appropriate nutrition whenever she

cries for feeding at times due to financial restraints.

People who are orally fixated exhibit signs such as sucking thumb

beyond toddlerhood, biting or always puting objects into her mouth such

as a pen or a pencil. This could be one of the factors involved in the

client’s smoking vice.Client is now at Genital stage; however, her coping

skills are underdeveloped.

According to Erik Erickson

Client was unsuccessful in her industry vs. inferiority task during her

school age years. She has not developed a sense of competence and

perseverance which lead to her withdrawal from school. Due to this

failure, she has difficulty progressing through the adolescent central task

of identity vs. role confusion. Client is making no effort to actualize her

abilities.She is indecisive and has antisocial tendencies, like withdrawing

from her significant others and getting involved in illegal activities.

According Roger Gould

Client has not matured enough and based on her actions, has not

tried to assume a new adult role. Based on observation, client seemed to

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exhibit regression. During the whole student nurse-client interaction, client

seemed to be anxious that she’ll get separated from her mother.

Cognitive Development

According to Jean Piaget

Rational thinking and deductive and futuristic reasoning of the

formal operations phse has not been observed by the student nurse from

the client. Priamary reason for this is the client’s current state: psychosis

due to substance abuse, specifically cocaine. Due to this fact, the student

nurse faces a great challenge on how to do health teaching effectively.

Moral Development

According to Laurence Kohlberg

Conventional stage and Interpersonal concordance orientation

basically speaks of societal pressure.

Aside from being genetically predisposed, one of the factors that

lead to the client’s condition was her peers. At 15, she got mixed up with a

bad crowd and started using drugs due to peer pressure. “Gipasuway man

ko nila,” as verbalized by the client when asked regarding the start of her

vice.

According Carol Gilligan

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There was a time when the student nurse touched the topic about the

client’s siblings. Before that, the client answered the student nurse’s

questions sensibly; however, when asked how were her siblings at home

and whether she missed them or not, the client exhibited circumstantiality.

She tried to avoid the topic. Her mother said that the client is deeply

concerned when it comes to her siblings. During her stay in the ward,

whenever she has extra food, she would tell her mother to save it for her

siblings. These behaviors gave the student nurse clues as to the client’s

sense of responsibility. She’s concerned not only on her own welfare but

also that of her siblings’.

Spiritual

The spiritual development has proved to be difficult to assess in a

person like April who is suffering from a substance abuse psychosis and

who refuses to answer when it comes to questions such as: do you think

what you are into now is a punishment from God?

Her mother stated that she goes to church and prays with the family

whenever her mother makes an enough effort to encourage her.

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2. Mental Status Exam

A. Appearance

Client was seen wearing a red shirt and maong pants, with a brown step-in

sandals to match. She was not wearing any make-up. The only accessory she had

on was a multi-colored bracelet in her left arm. Client is thwenty years old and

looks her age. She has dry skin and on it are four genuine tattoos found on her left

ring finger, another one on her forearm(dorsal part), on her scapular region which

was shaped like a cross, and on her right lower extremity.

B. Affect

Client’s facial expression does not convey emotion most of the time, that

was during the student nurse-client interaction. It remained constant all through

out the conversation.

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C. Behavior, Attitude and Coping Patterns

During the whole interaction, client did not exhibit any strange,

threatening, and violent behavior. She just sat on a bench, cross-legged. No

evidence of unusual mannerisms or motor activity. She has a normal gait and

posture. Client appeared to be evasive as evidenced by her short statements and

stands up whenever the student nurse sits beside her. During interviews, she

seemed to prefer sitting beside her mother.

D. Communication and Social Skills

Client spoke coherently and enunciated clearly. She responded only when

questioned and spoke with a loud voice. Client did not exhibit neologism nor

verbigeration; however, when asked about her family, she displayed

circumstantiality, stating unnecessary details irrelevant to what was being asked.

E. Content of Thought

Client claimed to have not experienced any delusions nor any kind of

hallucinations. No outward signs of compulsion and obsessions.

F.Orientation

During the two interactions that took place, client appeared to be person-

oriented, place-oriented and time-oriented. When asked, client could say her name

in full.
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G.Memory

When asked, client could recall certain fragments about her childhood and

high school life.She was able to tell the student nurse what happened hours prior

to her admission to the psychiatric ward.

H. Intellectual Ability

Client can use facts comprehensively. When asked if she can recall student

nurse’s name, client discretely glanced at the student nurse’s name plate which

indicates that she can read.Client can do simple mathematical equations such as

addition, subtraction, multiplication and division but has difficulty counting

backwards.

I. Insight Regarding Illness or Condition

Client was in denial of her condition.”Dili ko praning kay wa ko gagamit,”

as verbalized by the client referring to her state.

J. Spirituality

Client is a Roman Catholic. Does not respond when asked about her

spiritual values.

K. Sexuality
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Client haven’t express any concerns regarding sexual identity and function

. According to her mother, she did not have any boyfriend since she was sixteen

years old.

When April was fourteen years old, she was admitted by her boyfriend at

North General Hospital due to massive bleeding. She was diagnosed to have had

uterine laceration.

L. Neurovegetative Changes

Client claimed to have no difficulty falling and staying asleep at night,

despite their current condition. They currently sleep on a bench in the Psychiatric

ward common room. Client’s appetite has improved according to her mother. Her

mother stated that the client seldom eats at home, especially when she’s “tama”.

Client defecates regularly, according to her mother.

3. Psychopathology and Rationale

3.1 Normal Anatomy and Physiology of Organ and System Affected

The Brain

The adult brain’s unimpressive appearance gives few hints of its

remarkable abilities. It is about two

good fistfalls of pinkish gray tissue,

wrinkled like a walnut, and with the

texture of cold oatmeal. It weighs a

little over three pounds. Because the

brain is the largest and most

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complex mass of nervous tissue in the body, it is commonly discussed in

terms of its four major regions- cerebral hemispheres, diencephalons, brain

stem and cerebellum.

Speech, memory. Logical and emotional response, as well as

consciousness, interpretation of sensation and voluntary movement, are all

functions of cerebral cortex neurons.

The major structures of the diencephalon are the thalamus, which

encloses the shallow third ventricle of the brain, the hypothalamus which is an

important part of the limbic system and the epithalamus which has the pineal

gland and choroids plexus.

Structures of the brain stem are the midbrain, wherein reflex centers for

vision and hearing are found, the pons which is involved in the control of

breathing and the medulla oblongata which regulate vital visceral activities.

The Limbic System

The limbic system sets the emotional tone of the mind, filters external

events through internal states( emotional coloring), tags events as internally

important, stores highly charged emotional memories, modulates motivation,

controls appetite and sleep cycles, promotes bonding, directly processes the

sense of smell, and modulates libido.

The Blood-Brain barrier

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No other body organ is so absolutely dependent on a constant

internal environment as is the brain. Other body tissues can withstand the

rather small fluctuations in the concentrations of hormones, ions and nutrients

that continually occur, particularly after eating or exercising. If the brain were

exposed to such chemical changes, uncontrolled neural activity might result-

remember that certain ions (Na and K) are involved in initiating nerve

impulses, and some amino acids serve as neurotransmitters. Consequently,

neurons are kept separated from blood borne substances by a so-called blood

brain-barrier, composed of the least permeable capillaries in the whole

body.Of water soluble substances, only water, glucose and essential amino

acids pass easilty throught he walls of these capillaries.The blood brain barrier

is virtually useless against fats, respiratory gases and other fat-soluble

molecules that diffuse easily through all plasma membranes.This explains

why blood-borne alcohol, nicotine, cocaine and anesthetics can affect the

brain.

3.2 Psychopathology

A large number of toxic or psychoactive substances can cause

psychotic reactions. Such substance-induced psychosis can occur in multiple

ways. First, people may inadvertently ingest toxic substances by accident,

either because they don’t know any better or by mistake. Alternatively, people

may take too much of a legitimately prescribed medicine, medicines may

interact in unforeseen ways or doctors may miscalculate the effects of

medicines they prescribe. Finally, people may overdose on recreational drugs

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they commonly use ( such as cocaine), or become dependent on drugs or

alcohol and experience psychotic symptoms while in withdrawal from those

substances. This is basically what happened to April Michelle Tecson.

Cocaine is a naturally occurring alkaloid found within the leaves of a

shrub, Erythroxylon coca.. In the late 19th century, Sigmund Freud proposed

cocaine for the treatment of depression, cachexia, and asthma. It later became

prescribed for almost any illness and could be found in numerous tonics. In

1885, John Styth Pemberton registered a cocaine-containing drink in the

United States. This drink was later named Coca-Cola. In 1914, the Harrison

Narcotics Act banned all nonprescription use of cocaine. Finally, in 1970, the

Controlled Substances Act prohibited the possession of cocaine in the United

States, except for limited medical uses. The Diagnostic and Statistical Manual

of Mental Disorders notes that a diagnosis is made only when the psychotic

symptoms are above and beyond what would be expected during intoxication

or withdrawal and when psychotic symptoms are severe. The following are

the criteria necessary for diagnosis:

• cessation or reduction in previously heavy or prolonged cocaine use

• The patient also must have a dysphoric mood associated with 2 of

the following 5 physiological changes:

-Fatigue

-Vivid unpleasant dreams

-Insomnia or hypersomnia

-Increased appetite
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-Psychomotor agitation or retardation

• These signs or symptoms result in significant distress in the patient

clinically and may impair the patient's social or occupational areas of

functioning. The patient may experience significant depressed mood

with suicidal ideation.

• Mental status examination may show a sleepy, slowed-down patient

who complains of depressed mood and has a restricted affect. They

may express suicidal ideation.

Fig. 1 Schematic Diagram of Psychopathology of the illness

Predisposing Factors
Biological Precipitating Stressors
-genetics
-brain damage  financial constraints
From previous disease:  personal inadequacies
meningitis  peer pressure
 Psychological
-unresolved self-conflicts
-failed developmental tasks
Environmental
-deficiency of vitamin B
complex
-viral infection
Spiritual
-financial status
-relationship with members of
the community

Blockade of catecholamine reuptake

occuring in both the central and peripheral
nervous systems
(ie, norepinephrine, dopamine, and serotonin
reuptake blockade)
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Signs and Symptoms

Delusions; flight of ideas; alogia;hallucination

Medical Management Nursing Management

-stabilize psychotic symptoms -eliminate alcohol and substance abuse;

with medications monitor for suicidality and homicidality;
decrease environmental stress; promote
healthy relationship; encourage verbalization
of problems and assist in art therapy and
remotivation therapy

3.3 Disease Process and its Effect on the Different organ/system

Phase1(crash) Phase2(withdrawal)
9hrs.-4days 1-10 weeks

Early Early
Cocaine Binge dysphoria- Sleep normalized
depression,anxiety Euthymic mood
and agitation Low cocaine
craving
Middle Low anxiety
Fatigue
Depression Middle&Late
No cocainecraving Anhedonia
Insomnia with Anergia
increased need for Anxiety
sleep High cocaine
craving
Late Conditioned cues
Exhaustion exacerbate craving
Hypersomnolence craving
Hyperphagia
No cocaine Phase3(extinction)
craving indefinite
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Normal hedonic response

Euthymic mood
Episodic craving
Conditioned cues triggering
craving

abstinence

Fig. 2 Pattern of Cocaine Use

Cocaine has a number of pharmacologic effects on the human body.

Neuronal fast sodium channel blockade produces a local anesthetic effect that

continues to be used in medicine today. During myocardial fast sodium

channel blockade, cocaine blocks fast cardiac sodium channels, which results

in type I antidysrhythmic activity. This may lead to prolongation of the QRS

complex and contribute to the induction of the dysrhythmias associated with

cocaine use.

Blockade of catecholamine reuptake (ie, norepinephrine, dopamine,

and serotonin reuptake blockade) occurs in both the central and peripheral

nervous systems. Blockade of reuptake of norepinephrine leads to the

sympathomimetic syndrome associated with cocaine use. This syndrome

consists of tachycardia, hypertension, tachypnea, mydriasis, diaphoresis, and

agitation. Inhibition of dopamine reuptake in the CNS synapses, such as in the

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nucleus accumbens, contributes to the euphoria associated with cocaine.

Norepinephrine release augments norepinephrine reuptake blockade effects.

Cocaine abuse is associated with numerous detrimental health effects.

All organ systems can be adversely affected by its use. Cocaine-related

psychiatric disorders have been well-documented in the literature. Ten

cocaine-induced psychiatric disorders are described in the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-

IV-TR).Some of them are cocaine withdrawal, cocaine-induced psychotic

disorder with delusions and Cocaine-induced psychotic disorder with

hallucinations.

3.4 Classical and Clinical Symptoms

Classical Symptoms Clinical Symptoms Rationale

Delusion, fixed but false Client did not exhibit An excess of dopamine

beliefs delusions of grandeur affecting the cortical areas

-false sense of grandeur also of the brain.This gives the

called cocainomania client perceptions which are

not based on reality

Source:Psychiatric-Mental

Health Ng. by Shives

Flight of ideas When client talks she An excess of dopamine

sometimes jumps from one which results in the firing of

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topic to another.(refer to neurons with varied

process recording no.5) different and multiple

impulses to the brain

Source: Psychiatric-Mental

Health Ng. by Shives

Alogia, poverty of content Client often speaks very Organic functional changes

little or conveys little in the brain and cerebral

substance of meaning atrophy from imbalances in

neurotransmitter levels in

the brain.This decreases the

speed and how much

information is processed in

the brain.

Source: Psychiatric-Mental

Health Ng. by Shives

Hallucinations, most Client laughs by herself The excess of dopamine in

commonly tactile and the cortical areas of the

olfactory brain gives the client

perceptions which are not

based on reality

Source: Psychiatric-Mental
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Health Ng. by Shives

Anhedonia (loss of pleasure Client rarely interacts with A negative symptom caused
or interest)
her siblings anymore and by an inadequate amount of

does not engage in activities dopamine, cerebral atrophy

that used to be fun for or organic functional

her .This is according to her changes that the client’s

mother. brain may have undergone.

Source: Psychiatric-Mental

Health Ng. by Shives

Client does not engage in A negative symptom caused

Anergia( lack of energy)
activities that used to be fun by an inadequate amount of

for her .This is according to dopamine, cerebral atrophy

her mother. or organic functional

changes that the client’s

brain may have undergone.

Source: Psychiatric-Mental

Health Ng. by Shives

Client gets anxious This is caused by an

Anxiety
whenever her mother is not inadequate amount of

beside her. dopamine, cerebral atrophy

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or organic functional

changes that the client’s

brain may have undergone.

Source: Psychiatric-Mental

Health Ng. by Shives

High cocaine craving

Not exhibited by the client. Inhibition of dopamine

reuptake in the CNS

synapses, such as in the

nucleus accumbens,

contributes to the euphoria

associated with cocaine

which in turn triggers

intense craving.

Source: Davis, F.A. Taber’s

Cyclopedic Medical

Dictionary
 31

IV. Nursing Intervention

1. Care Guide of Patient with Substance-induced Psychosis

a. Treatment Settings

Residential programs/ therapeutic communities may be helpful.A

client typically spends six to twelve months in such programs, which may

also include vocational training and other features. But of course, the

client’s financial status and ability to cover treatment is also an issue that

affects the patient’s access to treatment. Dr. Yazar have recommended that

April be transferred to a drug rehabilitation center but April’s mom still has

difficulty finding a rehabilitation center that they can afford.

b. Psychotherapy

Contingeny management rewards drug abstinence( confirmed by

urine testing) with point or vouchers which patients can exchange for such
 32

things as an evening out or membership in a gym. Cognitive behavioral

therapy help users learn to recognize and avoid situations most likely to lead

to cocaine use and to develop healthier ways to cope with stressful situations

most likely to lead to cocaine use and to develop healthier ways to cope with

stressful situations.

Clients in similar situation with April should also be assessed for risk

of harm to self or to others. This also may mandate further inpatient care.

Careful assessment for suicidal ideation, plans, and level of intent to act on

such ideation is crucial. If a plan and intent to act is present, psychiatric

hospitalization is almost always warranted, even if requiring involuntary

commitment. Also, assessing homicidal ideation, intent, and plan is critical.

Not only may the patient require voluntary or involuntary psychiatric

hospitalization, but one also may have a duty to warn an intended victim.

Supportive therapy helps patients to modify their behavior by

preventing relapse by taking actions such as staying away from drug-using

friends and from neighborhoods or situations where cocaine is abundant.

Behavioral therapies have been designed to prevent relapse in

patients addicted to cocaine. These therapies help minimize exposure to drug

cues and help modify patients' responses to cues they encounter. For example,

a relapse prevention strategy may include minimizing the free cash the

cocaine addict has available to buy drugs. Another example is behavioral

therapy such as contingency management, in which vouchers are provided

and are redeemable for goods or services contingent on performance of

 33

desired behaviors.

c. Diet and Nutrition

The student nurse should promote adequate fluid intake ( 2,500-

3000 cc/ day) and promote intake of fresh fruits, vegetables and bran

products. These are precautionary measures to lessen the side effect of

psychotropic drugs given . Constipation is a common side effect of the drugs

given to April.

The use of low calories or sugarless hard candy, mints, gum or

beverages is encouraged if the client experiences dry mouth as a side effect.

Nausea and vomiting or irritation may present as a transient side

effect so medication must be taken with food. With the help of the dietitian

or nutritionist, April can be given a more holistic care.

d. Medications

There are numerous medications have been studied for the

treatment of cocaine addiction, and many show promise. Topiramate, an

anticonvulsant, shows some promise for cocaine-dependent patients.

Baclofen and tiagabine, as well as modafinil have also shown promise in

reducing cocaine use. Disulfiram may increase the aversive effects of cocaine

and reduce its use. Other recent work has suggested that a cocaine vaccine

may induce the formation of sufficient antibodies to reduce cocaine use.

 34

As of now, April has been given Haloperidol, Chlorpromazine and

Biperiden. Haloperidol is an antipsychotic nonphenothiazine while

chlorpromazine is also an anti-psychotic but that of the phenothiazine type.

Biperiden, an antiparkinsonian, is given as a prevention of the

extrapyramidal side effects that accompany phenothiazine therapy.

 35

2. Actual Patient Care:

2.1 Nursing Care Plan

Name of Client: April Mechelle Tecson Age: 20 years old Hospital No. 6184112 Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII Physician: Dr. Yazar

Nursing Care Plan

Needs/Problem Nursing Scientific Basis Objectives of Nursing Actions Rationale

Cues Diagnosis Care

I. Psychologic Goal: Measures to:

deficit: After 2 weeks

of student I. improve the quality of

A. Impaired Impaired Cocaine nurse-client verbal communication

verbal verbal produces interaction, the

communication communicat pleasurable client will be 1. attempt to decode 1.reveal how the client is

ion: effects through able to establish incomprehensible being perceived by others

Cues: incomprehe its action on trust, gain communication patterns while the responsibility of

nsible structures deep rapport, gain understanding the client is

 36

-client’s statements within the insight of accepted by the student

statements are related to brain-most reason of nurse pg.285-286;

often looseness of notably, a admission and Psych.Ng. by Townsend

incomprehensi association region called show adaptive

ble the ventral attitude towards 2. seek validation and 2.prevents making

- client is silent segmental area. stressful clarification on ambiguous assumptions and genuinely

most of the A cocaine binge situations statements attempts to understand

time but when (repeated use client-pg.285-286;

talked to, with increase Specific Psych.Ng. by Townsend

responds in a amount) may Objectives:

loud voice cause increasing After 30-45 3.facilitate trust and 3.This approach conveys

-client usually irritability, min. of student understanding by empathy and may

responds in restlessness and nurse-client maintaining staff encourage client to disclose

short paranoia; interaction, the assignments as possible painful issues-pg.285-286;

statements and possible client will be Psych.Ng. by Townsend

sometimes resultant able to:

 37

does not fullblown 4. anticipate and care for 4.Client’s safety and

respond at all paranoid 1.express client’s needs until comfort are nursing

-“Tan-aw nila psychosis, loss herself functional communication priorities-pg.285-286;

ug praning na of touch of effectively , as pattern returns Psych.Ng. by Townsend

ko,” as reality and efvidenced by

verbalized by auditory an interaction 5. orient client to reality by 5. These facilitate

the client hallucinations. wherein her name and validate those restoration of functional

Pg. 293, responses can aspects of communication communication patterns of

Straight A’s in be understood that help differentiate client-pg.285-286;

Psychiatric by the student between what is real and Psych.Ng. by Townsend

Mental Health nurse what’s not

Nursing;

Lippincott

Williams &

Wilkins

B. Impaired Impaired The deep limbic 2. effectively II. promote social

 38

social social system/structure communicate interaction

interaction interaction: s are also with the student

difficulty intimately nurse as 1. encourage client to 1.actively listen to note

Cues: maintaining involved with evidenced by verbalize problems and indications of hopeless

-client has eye contact bonding and maintenance of perceptions of reasons of ness, powerlessness,

difficulty related to social eye contact and problems anxiety, grief and hate-

maintaining client’s connectedness. improved pg.481,Nursing Care Plan

eye contact withdrawal When the deep responses to by Doenges

-client has a from society limbic system is student nurse’s

“glazed look” damaged due to questions 2. determine the use of 2. It affects the ability to be

-client answers several factors coping skills and defense involved in social

curtly in short such as trauma mechanisms interactions-pg. 483,

statements and chemical Nursing Care Plan by

most of the hzzards, the Doenges

time ability to

-“Excuse sa te connect with 3. encourage client to keep a 3. to keep a baseline data

 39

ha,” as other people on daily journal of social for changes/;

verbalized by a social level is interactions improvements or

the client affected. exacerbations- pg. 483,

Nursing Care Plan by

-pg. 1953-1956; Doenges

Taber’s

Encyclopedic 4. assist the client to develop 4. to slowly reorient client

Medical positive social skills through to the reality of social

Dictionary by practice of skills in real interaction- pg. 483,

F.A. Davis social situations Nursing Care Plan by

accompanied by a support Doenges

person, and

5. encourage reading, 5. to reorient the client to

listening to news and reality while not yet fully

remotivation therapy exposing her to full social

 40

interaction- pg. 483,

Nursing Plan;Doenges

II. Psychologic Impaired A cocaine binge 3. exhibit a III. decrease erratic thinking
processes:
overload: thought may cause coherent train
1. reorient the client to
processes: increasingly of thoughts, as the time, place and 1. to promote reality based
day
A. Impaired inappropriat irritability, evidenced by interaction-pg.531, Nurse’s

thought e answers to restlessness and the client Pocket Guide; Doenges

processes questions paranoia; sharing one past

related to possible experience and 2.to provide stimulation

2. schedule structured
Cues: circumstanti resultant full- can be activities and rest without undue fatigue-
periods
- inappropriate ality blown paranoid understood by pg.531, Nurse’s Pocket

answers to psychosis, loss the student Guide; Doenges

questions of touch of nurse.

-usually reality and 3. to clarify and simplify

responds in auditory 3. give simple activities for the client-pg.

 41

short hallucinations. questions 532, Nurse’s Pocket

statements –pg.293, Guide; Doenges

-do not respond Straight A’s in 4. to refocus conversation

directly Psychiatric in one topic-pg. 532,

Nursing; Nurse’s Pocket Guide;

4. ask leading questions
Lippincott Doenges

Williams 5. to refocus conversation

in one topic-pg. 532,

Nurse’s Pocket Guide;

5. clarify and refocus if
client exhibits
circumstantialit

2.2 Brunswick Lens Model

Measures to:
Name of Client: April Mechelle Tecson Age: 20 years old Hospital No. the
I. improve 6184112
quality of verbal Date: 09/17/07
communication
- attempted to decode incomprehensible communication
Diagnosis: Substance-induced psychosis Sex: Female Ward patterns
No. XII Physician: Dr. Yazar
- sought validation and clarification on ambiguous
I. Psychologic deficit: II. promote social interaction
statements
A. Impaired verbal communication --facilitated
encouraged client
trust andtounderstanding
verbalize problems and perceptions
by maintaining staff of reasons of
-statements are often problems
assignments as possible
incomprehensible -- determined
anticipated and the use
careoffor coping
client’s skills
needsanduntil
defense mechanisms
functional
- silent most of the time -communication
encouraged client to keep
patternthinking a daily journal
returns processes: of social interactions
B. Impaired social interaction III. decrease
-assisted the erratic
client to develop positive social skills
II.-client usually
Psychologic
-client has responds
overload:
difficulty in shorteye contact
maintaining -oriented
-reorientedclientthetoclient
realitytoby thename
time,and validate
place and those aspectspractice of
day
through
skills in real
of -scheduled
communication social situations
that help accompanied
differentiate by
betweena support
what isperson, and
statements
A.
-clientImpaired thought
has a “glazed processes
look” Specific Objectives:-encouraged structured
reading, activities
listening to and rest
news and periods
remotivation therapy
-“Tan-aw nila ugcurtly
- inappropriate praning
answers na ko,” as II. Impaired
to questions I. Impaired
social interaction:
verbal
After communication:
30-45 difficulty real
min. of student
andnurse-client
-gave what’s questions
simple notinteraction, the client will be able
-client answers in short statements most of theGoal:After 2 weeks of student nurse-client interaction, the
verbalized by the client
-usually responds in short statementsIII Impaired
maintaining thought processes:
incomprehensible
eye contact
to: related
statements
to client’s - asked leading questions
time inappropriate client
answers will
to be able
questions to establish trust, gain rapport, gain insight
-do not sarespond withdrawal related 1.express of
fromtosociety
looseness herself
association - clarified
effectively and refocus
, as evidenced by an if interaction
client exhibits circumstantiality
wherein her
-“Excuse te ha,”directly
as verbalized by the client
related to of responses
reason of admission
circumstantiality and showbyadaptive
can be understood the studentattitude
nursetowards
Actual
Of patient’s
state condition Cues Nursing Diagnoses
stressful situations Nursing Actions Desired Outcome
 42

2.3 Drug Therapeutic Record

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Drug Therapeutic Record

Drug/Route/Do Classification/ Indication/Contrain Principles of Treatment Evaluation

sage/ Mechanism of dication/ Adverse Care

Timing action effects

Haloperidol, Typical anti- I:

PO, 20mg, ½ psychotic ;  manageme  do not allow  encour Client’s blood

tab, OD nonphenothia nt of client to crush age pressure was

8am zine manifestations or chew client to taken before she

of psychotic medication to join in was given the

MOA: disorders prevent therapies medication.

Mechanism  control of decrease in  orient “Muinom ra

not fully tics in absorption and client to pud biya siya.

understood. Tourette’s effectiveness reality Dili ra

Provides a syndrome  advise client by not pugsunon”, as

symptomatic  behavioral to avoid being encourag verbalized by

control for the problems in in direct ing the client’s

client by children with sunlight for an distorted significant

blocking the combative, extended time perceptio other.

activity of explosive;hype  good oral ns of

 43

dopamine, rexcitability;sh hygiene reality

which has the ort-term should be  encour

potential to  treatment encouraged to age

produce for children avoid mouth complian

psychotic with excessive infections ce of

thinking. Too motor activity,  assist in taking

much mood lability CBC medicati

dopamine C/I: monitoring ons on

causes nerve  hypersensitivity  monitor for time

impulses in  Parkinson’s early signs of  discour

the brain stem disease extrapyramida age use

to be  liver damage l side effects of

transmitted A/E: alcohol

faster than  anticholinergic and other

normal, effects: dry additive

resulting in mouth,drowsines drugs

strange s, nasal
thoughts and congestion,
hallucinations constipation
. Also has
 dermatitis
anti-emetic
 photosensitivity
property.
 GI distress

 weight gain
 44

 extrapyramidal

side effects

source: pg.

235,

Psychiatric-

Mental

Health Ng. by

Shives
 45

Drug/Route/Do Classification/ Indication/Contrain Principles of Treatment Evaluation

sage/ Mechanism of dication/ Adverse Care

Timing action effects

Chlorpromaz Typical , anti- I:

ine psychotic,  manageme  do not allow  encour Client’s blood

hydrochlorid phenothiazine nt of client to crush age pressure was

e,PO, 100mg, manifestations or chew client to taken before she

I tab, OD at MOA: Not of psychotic medication to join in was given the

hour of sleep fully disorders prevent therapies medication.

understood.  relief of decrease in  orient “Muinom ra

Blocks preoperative absorption and client to pud biya siya.

postsynaptic restlessness; effectiveness reality Dili ra

dopamine control of  advise client by not pugsunon”, as

receptors in manic- to avoid being encourag verbalized by

the brain. depressive in direct ing the client’s

Depresses illness sunlight for an distorted significant

those parts of  adjunct extended time perceptio other.

the brain treatment of  good oral ns of

involved with tetanus hygiene reality

wakefulness  therapy should be  encour

and emesis; for encouraged to age

anticholinergi combativeness, avoid mouth complian

c, hyperactivity infections ce of

antihistaminic  control of  assist in taking

 46

and alpha- nausea and CBC medicati

adrenergic vomiting monitoring ons on

blocking C/I:  monitor for time

 hypersensitivity early signs of  discour

source: pg.  Parkinson’s extrapyramida age use

235, disease l side effects of

Psychiatric-  Coma alcohol

Mental  Bone marrow and other

Health Ng. by depression additive

Shives A/E: drugs

 anticholinergic

effects

 dermatitis

 photosensitivity

 GI distress

 extrapyramidal

side effects
 47

Drug/Rout Classification/ Indication/Contrain Principles of Treatment Evaluation

e/Dosage/ Mechanism of dication/ Adverse Care

Timing action effects

Biperiden Antiparkinsonian I:

hydrochl  adjunct  drug  encourag Client’s

oride, MOA: Blocks the therapy of should be e client to blood

PO, 2mg, action of parkinsonism tapered take pressure

1 tab, OD acetylcholine in  relief of gradually to antipsycho was taken

the brain and extrapyramidal prevent tic before she

peripheral side effects that withdrawl medication was given

nervous system in accompany symptoms s exactly the

attempt to correct phenothiazine  advise as medicatio

an imbalance therapy client to prescribed n.

between a C/I: avoid the  do health “Muinom

deficiency of  hypersensitivity use of teaching to ra pud

dopamine and  glaucoma alcohol,sedat the client’s biya siya.

abundance of  myasthenia ive and over significant Dili ra

acetylcholine. gravis the counter other pugsunon”

drugs regarding , as
 prostatic

 advise the early verbalized

hypertrophy

against signs of by the

A/E:
source: pg. 235,
staying long extra client’s
Psychiatric-  psychosis
under the pyramidal significant
Mental Health  depression
sun side other.
Ng. by Shives  hallucinations
 48

 insomnia effects

 irritability  encourage

complianc

e of taking

medication

on time

2.4 Health Teaching Plan

 49

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Health Teaching Plan

Objectives Content Methodology Evaluation

General:

Within 2 weeks of

student nurse-client

interaction, the

client wil be able to

acquire adequate

knowledge, attitude

and skills regarding

the use of coping

skills whnever the

need arises.

Specific:

Within 45 min. of

student nurse-client

interaction, the

client will be able

to:
 50

1. state the 1.Importance of Informal discussion Client was barely

importan using a coping listening. She easily

ce of mechanism gets distracted by the

using -reduces stress events around her.

coping and lightens up However, at the end of

mechanis your mood the health teaching she

m -reduces anxiety stated the that she

-enables a Informal discussion prefers writing on a

person to still journal as a means of

function in work coping.

despite current

crisis

2. Hazards of not

being able to use

proper coping

mechanisms

2. identify -person would turn

health to vices like

hazards smoking, drinking, Informal discussion

of not drugs

being -aggravates mental

able to illness

use 3. enumerate coping

 51

coping mechanisms

mechanis available

ms -talking to a

dcuring bestfriend or

stressful significant other

situation about problems

s -putting troubling

thoughts in a journal Informal discussion Client stated that she

-drawing preferred writing on a

-listening to music journal as a means of

-playing sports coping.

-joining in yoga and

3. enumerat other relaxation

ed classes Informal discussion “Gahanan ko

coping 4. choose a coping magsuwat.,” as

mechanis mechanism she is verbalized by the

ms comfortable with client..

available 5. client’s

verbalization of

willingness to use

the coping

mechanism
 52

4. choose a

coping

mechanis

m she is

comforta

ble with

5. verbalize

willingne

ss to try

to use

the

coping

mechanis

2.5 SOAPIE and Process Recording

 53

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

SOAPIE No.2

S- “Maayong buntag,” as verbalized by the client

O- client is still silent most of the time but responds with a loud voice when talk to,
usually responds in short statements and when asked about her siblings, she does not

respond correctly; instead, exhibits circumstantiality

A-Impaired thought processes: inappropriate answers to questions related to

circumstantiality

P- to decrease erratic thinking process

I- reoriented the client to the time, place and day; scheduled structured activities and rest
periods; gave simple questions; asked leading questions; clarified and refocused if client

exhibits circumstantiality

E- client was still not ready to openly discuss her troubled past

Student nurse: Casinillo, Rhia Marie B.

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07
 54

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

SOAPIE No.3

S- “Excuse sa te ha,” as verbalized by the client

O- -client has difficulty maintaining eye contact; client has a “glazed look”; client

answers curtly in short statements most of the time

A- Impaired social interaction: difficulty maintaining eye contact related to client’s

withdrawal from society

P- to promote social interaction

I- . encouraged client to verbalize problems and perceptions of reasons of problems;

determined the use of coping skills and defense mechanisms; encouraged client to keep a

daily journal of social interactions; assisted the client to develop positive social skills

through practice of skills in real social situations accompanied by a support person, and

encouraged reading, listening to news and remotivation therapy

E- client still answered in short statements but was able to stay with the student nurse for
approximately 5 minutes without the presence of her mother

Student nurse: Casinillo, Rhia Marie B.

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07
 55

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Process Recording No. 1

I. Objectives

a. General Objective:

After 2 weeks of student nurse-client interaction, the client will be able to

establish trust, gain rapport, gain insight of reason of admission and show adaptive

attitude towards stressful situations.

b. Specific Objectives:

After 30-45 min. of student nurse-client interaction, the client will be able to:

1. establish trust on the student nurse-client interaction, the client will be able to:

1.1 maintaining eye contact during interaction

1.2 asking questions

2. abide by the “lagda” or contract set by the student nurse and agency

3. show essential details that lead to client admission

4. verbalize feelings and concerns as regarding present situation

5. agree to date, time and place of the next interaction

 56

II. Setting

a. Date: September11, 2007

b. Time: 11:00 am to 11:30 am

c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the

common room

III. Appearance

The client was seen sitting on a bench in the common room. She was wearing a

relatively clean black shirt and pink pants. He rhair was neatly combed. Her belongings

were packed in a bag. She was well taken care of by her mother who was with her since

her admission to the center, which was last September 8, 2007.

IV. Behavior

The client was cooperative; communicates but in short statements only. She maintains

eye contact when talked to. She was silent most of the time. She does not mingle with

other patients and preferred sitting with her mother.

V. Communication

The client did not exhibit neologisms, nor of pressured speech but exhibit flight of

ideas, jumping from topics unrelated to the current topic of discussion and inability to

concentrate. Client communicates in a loud voice.

 57

VI. Interaction

Student Client’s verbal/ Communication Client’s Analysis

nurse’s verbal/ non-verbal technique used Defense

non-verbal communication Mechanism

communication

“Maayong Client nods and Giving -none used- The nurse calls

buntag A.T.” stares at the recognition the client by

student nurse name to boost

the client’s self-

esteem and

promote

reorientation to

her identity.

“Ako diay si “Estudyante sa Giving -none used- This action

Rhia, imong Cebu Doc?” information helps facilitate

student nurse na trust and build

gikan sa Cebu rapport by

Doctors’ giving

University” information

about self or

one’s self to the

client.
 58

“Makahatag ka “Gidala ko nila Asking direct -none used- The nurse asks

sa eksaktong Papa kay question a question by

adlaw, petsa ug praning daw ko. interaction, to

oras? Ug kung Gidala ko dire assess the

asa ta?” sa Sotto atong client’s

Sabado” orientation.

Client pauses

and stares at

student nurse.

“Murag Martes

ta karon”

“Sakto na “Dili wala koy Exploring -none used- The nurse

Martes ta karun. orasan” delves deeper to

Setyembre 11, further assess

2007.Makahatag the client’s

ka sa eksaktong orientation to

oras karon?” reality and

ensure that

client is not just

guessing.
 59

Nurse provides

“Alas onsi kapin Client nods Giving -none used- information to

ta karun sa information orient client to

buntag.” reality.

The nurse asks

“Kumusta man “Ganahan na ko Asking direct -none used- an open ended

ang imo pamati muoli.” open ended- question to

karun?” question facilitate

expression of

feelings

through

continued

communication.

“Unsa man ang Client lies down Exploring -regression- Nurse delves

rason na on her mother’s deeper to get

nakaingon ka lap. No answer. further

ana?” information.

VII. Evaluation
 60

Client was not very cooperative and appeared to be uncomfortable when the

student nurse talked to her and asked her questions. She exhibited regression when she

felt uncomfortable.

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Process Recording No. 2

I. Specific Objectives:

After 30-45 min. of student nurse-client interaction, the client will be able to:
 61

1. recall the name of the student nurse

2. state the present date, time and place of the current interaction

3.verbalize feelings about the client’s present condition

4. identify the reason for current hospitalization

5. set the date, time and place of the next interaction

II. Setting

a. Date: September 12, 2007

b. Time: 10:45 am to 11:15 am

c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the

common room

III. Appearance

The client was seen sitting on a bench in the common room. She was wearing a red

shirt with maong pants. The client was able to perform activities of daily living, as

evidenced by a neat and tidy appearance..

IV. Behavior

The client was constantly glancing outside the window. She was always standing up

to check the activities going on outside. Client can maintain eye contact for quite

sometime but her eyes wander off constantly when asked about her family.
 62

V. Communication

The client did not exhibit neologisms, nor of pressured speech but exhibit

circumstantiality, giving much unnecessary details that delay meeting a goal or stating a

point.

VI. Interaction

Student nurse’s Client’s verbal/ Communication Client’s Analysis

verbal/ non- non-verbal technique used Defense

verbal communication Mechanism

communication

“Maayong “Maayong Giving -none used- The nurse

buntag A.T.” buntag” recognition calls the

Client nods client by

name to boost

the client’s

self-esteem

and promotes

reorientation

to her

identity.

“Nakahinumdum Client looks at Asking direct -none used- The nurse

 63

pa ka sa akong student nurse’s question asks a

pangan?” name plate question by

interaction, to

assess the

client’s

memory and

orientation

“Unsa man tang “Nakalimot Asking direct -none used- The nurse

adlawa kaun ko.Alas dose question asked a

A.T. ug unsang na” question by

orasa na?” interaction, to

“Karun kay “Okay” Giving -none used- assess the

Setyembre 12, information client’s

2007. Alas 10:50 memory and

sa buntag” orientation.

“Kumusta man “Okay ra Asking open -none used- The nurse

ang imong man.Gikan unta ended question provided

buntag?” ko sa gawas information

pero nisud ko to orient the

kay nay client to

gaaway” reality.
 64

“Nisud ka kay Client nods Restating -none used- The nurse

nahadlok ka sa asked an

gaaway?” open ended

question to

start a

conversation.

“Nya unsa man “Wala” Client Asking direct -none used- The nurse

ang imo ganahan asked her open ended- restated the

buhaton karun?” mother to put question client’s

oil on her back. statement for

clarification.

“Sakit ba ang “Oo” Client Seeking -none used- The nurse

imong likod closes her eyes. information asked an

kaun?” “Panuhot” open ended

question to

continue

conversation.

“Ganahan jud Client’s mother Asking direct -none used- Nurse asked

diay ka na ang answered for question w the client is

 65

imong mama her: “Sukad pa feeling,

maghilot nimo, atong bata neh preventing

sah?” siya day formulation

ganahan na jud of

neh siya hiluton assumption..

nako. Lahi sa

iyang mga

igsoon”

Client closes

her eyes.

“Kinsa man ang Client stares at Seeking Negative Client gave

gabantay sa a distant object. information attitude: much

imong mga Kagwapa nimo Circumstantiality unnecessary

igsoon karun?” uy…ganahan detail stating

jud ko nimo” a point or to

divert Student

nurse’s

attention

from the

unwanted

topic.
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Avoidance The student

“Murag galibog Client does not Seeking nurse asked a

ko sa imong look at the clarification question to

tubag sa akong SN.She watches clarify the

pangutana.Unsa television client’s reply.

man ang imong instead.

pasabot?”

-none used- Student nurse

“Ganahan na ka Client looks at Giving and client

mopahuway the student information agreed

AT? Mubalik nurse. O, sige. reading the

lang ko ugma ha “Naa ra ko next meeting

sa pareho dire.” time and

gihapong place.

oras.Naa ra ka

dire gihapon?”

VII. Evaluation

Client was cooperative, answers questions but seemed distracted. She was awake,

alert and oriented, with no impairments in mobility. She did not seem to want to talk

about her family, as evidenced by the circumstantiality she exhibited at the last part of the

conversation.
 67

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Process Recording No. 3

I. Specific Objectives:

After 30-45 min. of student nurse-client interaction, the client will be able to:

1. recognize the student nurse

2. state the present date, time and place of the current interaction

3.respond to the student nurse’s questions appropriately

4. maintain eye contact for at least 3 seconds, and

5. agree with the student nurse regarding the date, time and place of the next

interaction

II. Setting

a. Date: September 13, 2007

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b. Time: 10:30 am to 11:00 am

c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the

common room

III. Appearance

The client was seen walking away from the area of the culminating activity carrying

with her a cellophane with food. Shea was walking towards her mother. Client was

wearing a brown halter top and pyjama pants. Her hair was neatly combed, and she was

clean from her bath.She has already brushed her teeth and attended to her personal needs.

IV. Behavior

The client was uncommunicative at first. Every time the student nurse tries to sit

beside her and start a conversation, she tries to excuse herself and walks toward her

mother. She became cooperative after a few minutes, after she was done eating her burger

and fries. She answered the student nurse’s questions. She did not exhibit any violent

behavior. She participated in the student nurse’s drawing therapy..

V. Communication

The client spoke in short, curt statement.She had no echolalias nor palilalias.She

exhibited looseness of association as evidenced by inappropriate answers to student

nurse’s questions.
 69

VI. Interaction
 Student Client’s verbal/ Communication Client’s Analysis

nurse’s verbal/ non-verbal technique used Defense

70
non-verbal communication Mechanism

communication

“Maayong Client nods Giving -none used- The nurse calls

buntag A.T.” recognition the client by

name to boost

the client’s self-

esteem and

shows that the

client is

recognized as

an individual.

The nurse asks

“AT, Kahibaw “Alas diyes. Asking direct -none used- a question by

kung unsa ang Naa ko sa question interaction, to

adlaw,petsa, ug gawas kay assess the

kung aha ta gaculminating.” client’s

karun?” memory and

orientation

To boost the

client’s

“Sakto na alas Client nods Acknowledgement -none used- confidence and

diyes ta and reorient her to

karun.Alas Asking direct reality.

diyes kwarentay question

10 minutes later…same setting
 71

VII. Evaluation

The student nurse-client interaction was more productive this time because client

was more cooperative and less avoidant compared with the previous conversations.

Student nurse was able to get through the barrier of communication (e.g. in her case, the

client’s significant other ; because student nurse has difficulty communicating with the

client whenever the significant other is around because client expects the significant other

to answer for her). Client was able to interact well with the individualized art therapy.

Her train of thought was coherent and intelligible.

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07
 72

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr.

Yazar

Process Recording No. 4

I. Specific Objectives:

After 30-45 min. of student nurse-client interaction, the client will be able to:

1. recognize the student nurse

2. state the present date, time and place of the current interaction

3. respond to the student nurse’s questions appropriately as to

3.1 content of client’s auditory hallucinations

4. participate in the news therapy, and

5. agree with the student nurse regarding the date, time and place of the next

interaction

II. Setting

a. Date: September 14, 2007

b. Time: 10:30 am to 11:00 am

c. Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the

common room
 73

III. Appearance

The client was seen sitting at a bench in the OPD with her mother.She was scheduled

for a n interview with Dr. Yazar. Client was well-groomed, wearing a clean brown shirt

with a clean maong pants. Howver, her hair wasn’t properly kempt, as if she just arouse

from bed. She has already taken a bath according to her significant other and has already

done her activities of daily living like brushing her teeth.

IV. Behavior

The client was much more cooperative compared with the previous interactions. She

exhibited signs of nervousness as evidenced by her frequent glancing at the stairs and at

the physician’s clinic door.

V. Communication

The client answered the student nurse’s questions regarding the content of her

auditory hallucination. Apart form, date and time disorientation, client was coherent all

throughout the interaction and was able to answer appropriately.

VI. Interaction

Student Client’s verbal/ Communication Client’s Analysis

nurse’s verbal/ non-verbal technique used Defense

non-verbal communication Mechanism

communication
 74

“Maayong Client smiles Giving -none used- The nurse calls

buntag A.T. “Interviewhon recognition the client by

Murag lipay ko ni doctor name to boost

lageh ka karun. para makauli na the client’s

Gaunsa man ka ko” self-esteem

dinhi?” and shows that

the client is

recognized as

an individual.

Assess the

“Nakulbaan ka Looks at the Asking direct -denial- client’s

para sa student nurse. question orientation to

interview?” “Okay ra man reality and

ko.Wa ra ko current

nakulbaan” emotional

Looks at the status.

stairs and then

the office door.

“makasulti ka Looks at the Asking direct -none used- Assessed the

kung unsa tan a stairs. question client’s

 75

adlaw, oras ug “Dominggo orientation to

kung asa ta man ta karun. reality.

karun AT?” Alas diyes.

Padung ko mag-

interview”

“Biyernes ta Client nods Giving -none used- Giving

karun AT.Alas “Sakto. Sakto” information information to

diyes sa buntag, orient the

Setyembre 14, client to

2007. Naa ta reality.

karun sa OPD

para sa imong

interview kang

Dr. Yazar”

“O, naa na Client nods "O, Asking direct -none used-

imong Doctor ,mao na question Assessed the

AT. Mao ban a siya.Excuse sa client’s

siya si Dr. ha.” orientation to

Yazar?” reality.

VII. Evaluation
 76

The student nurse-client interaction was brief but productive. Client was

cooperative and less avoidant. Student nurse was able to get through the barrier of

communication, which in this case, was her mother because the client does not usually

talk to the student nurse whenever her mother isn’t by her side.

Name of Client: April Mechelle Tecson Age: 20 years old Date: 09/17/07

Diagnosis: Substance-induced psychosis Sex: Female Ward No. XII

Physician: Dr. Yazar

Process Recording No. 5

I. Specific Objectives:

After 30-45 min. of student nurse-client interaction, the client will be able to:

1. recognize the student nurse

2. state the present date, time and place of the current interaction

3.recall the past experience with the student nurse for the past week

4. improve social interaction by joining the culminating activity

 77

5. terminate the therapeutic student nurse-client interaction

II. Setting

Date: September 17, 2007

Time: 8:30 am to 9:00 am

Place: Vicente Sotto Memorial Health Center Psychiatric Ward- bench in the common

room

III. Appearance

The client was seen sitting on a bench in the common room with her mother.She was

talking to her mother about her food and at the same time she was getting ready fo the

morning stretch. She had already taken a bath according to her mother. However, her hair

wasn’t properly kempt probably due to her frequent scratching of her head. Client was

wearing a white shirt and pyjamas.

IV. Behavior

The client was cooperative but exhibited irritability at some points of the interaction.

She was much more talkative during this interaction compared with the previous ones. In

fact, she was the one who initiated the conversation when the student nurse arrived at the

common room. She got irritated when she was asked the second time regarding the

current date and place.

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V. Communication

The client was much more talkative this time and was observed to have exhibited

flight of ideas. She often does not state her ideas coherently, making it difficult for the

student nurse to understand her statement. She easily gets distracted with ativities around

her as evidenced by her frequent standing up and glancing outside while the conversation

between the student nurse and client was going on.

VI. Interaction

Student Client’s verbal/ Communicatio Client’s Analysis

nurse’s verbal/ non-verbal n technique Defense

non-verbal communication used Mechanism

communicatio

Client smiles at -none used-

student nurse. “Hi

ate”

Student nurse Giving The nurse

smile at AT. recognition calls the

“Hi A.T.” client by

name to
 79

boost the

client’s self-

esteem and

shows that

the client is

recognized as

an individual.

“Kumusta man “Okay ra. Muapil Asking direct -none used- The nurse

ka karun?” ko ug question asks a

exercise.Mubalik question by

lang ko inig interaction, to

human na.Excuse assess the

sa ha.” client’s

orientation to

About 15 minutes reality.

later…

“Kumusta man Client smiles and Asking direct -none used- Assesed if
ang morning wipes sweat off question client is
stretch?” her forehead. aware of

“Hangak ug kapoy what is going

uy.” on around

her.
 80

“Naa pay music

therapy taod- “Di lang. mutan- Asking direct -none used- The nurse

taod, gusto ka aw ra ko” question provided

muapil AT?” information

to orient the

client to

reality and

give the

client a

choice as a

sign of

respecting

her dignity.

“Ah sige.AT,

makaingon ka Client smiles Asking direct -none used- Assessed if

kung unsa tan a “Alas nuwebe na question client is

oras , petssa ug daw ta. Muag oriented to

adlaw karun?” lunes ta karun, time and

diba?” date.

“O sakto ka na

alas nuwebe ta Client’s face Giving -none used- The nurse

karun.”Lunes turned serious information provided

ta. Pero and her smile information

 81

kahibaw ka faded. “Setyembre to orient the

unsa na na 17, 2007. client to

petsa?” Maminaws na ta reality.

ha!”

“O sige

maminaw na ta”

After about 5

minutes

“Ate naa kay

suwaton? Pwede none -none used- none

ako musuwat?

Ganahan man gud

ko magsuwat-
“Wala pero naa
suwat.” mother.
koy papel ug

crayon

dire.Suwat-

suwat lang,

tagaan tika.”

After about 5

minutes
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“Nindot ug agi

nimo “O, mao neh Giving Negative Giving

AT.Mahilig akong buhaton sa recognition communication recognition

diay ka bay” Client is : Flight of boosts the

magsuwat?” busy writing ideas client’s self-

“Sakto neh siya esteem.

ate? Pailisdan

nako akong T-

shirt unya ha”

“Unya na na

huna hunaa AT. Client nods. Refocusing -none used- The student

Mag focus sa ta “Sakto.sakto”. nurse

karun sa ato reoriented the

topic bahin pag- client to the

suwat suwat” present topic

of

conversation

and shifted

her attention

to what is

After about 5 presently

minutes discussed.
“AT naka

dumdum pa ka -none used-

 83

sa akong “O kanang mag Asking direct This was to

gitudlo nimo suwat o question assess if the

ato niaging magdrawing? Mas client was

adlaw? Kato ganahan ko mag able to retain

bahin sa mga suwat Te kaysa sa knowledge

buhaton nimo magdrawing” regarding

kung naa kay coping

problema?” mechanisms

taught by the

student nurse.

“Maayo kay

nakadumdum -none used- This boosts

pa ka” Client nods and Giving the client’s

smiles. recognition self

confidence.

“Ugma diay AT

kay magsturya -None used- T o make the

gihapon ta ha, Client nods. “O Giving client aware

sa pareho sige te.Timan-an information of the

gihapong lugar. nako tanan” upcoming

Timan-I tong activity and

akong inable her to

gipangtudlo act
 84

nimo ha” appropriately

“Last day na

diay na mo ug -none used- T o make the

ma AT. Hinaot Client looks at the Giving client aware

unta na student nurse. information of the

nakatabang ra "Dina ka mubalik upcoming

ko nimo. Apil te?” activity and

ta ug inable her to

culmination act

karong Friday appropriately

ha?”

“Di na mi

mubalik sunod -none used- Giving

semana. Lahi na Client smiles Giving information

pud ang student back. “Bye te” information facilitates

nurse na makig And expressing improve trust

amiga nimo. appreciation and

Salamat sa expressing

tanan AT” appreciation

Student nurse shows that

smiles at the client is

 85

client. being

recognized as

a person.

VII. Evaluation

The student nurse-client interaction was productive because client was more

cooperative. Student nurse was able to get through the barrier of communication ( e.g. in

her case, the client’s significant other ; because student nurse has difficulty

communicating with the client whenever the significant other is around because client

expects the significant other to answer for her). Client was able to interact well and was

able to assess whether the client has learned something from the previous interactions.

Client has improved a great deal since the first interaction as evidenced by more

productive and fruitful conversations as time went by.

 86

V. Evaluation and Recommendation

Many studies of short term out-patient treatment over a six-month to

two-year period indicate that people addicted to cocaine have a better chance

of recovering than people who are addicted to heroin.

Somehow, April’s being a young adult at the time she was admitted is

working to her advantage because it is during this time that a significant other

or care giver can guide and support her with her chosen lifestyle. Later than

this stage, it is much harder to convince her to change her lifestyle because

she may have already chosen one for herself.

Up to this point, the best recommendation in this case would be to

follow Dr. Yazar’s advice to transfer April to a drug rehabilitation center

wher3e needs and therapies specific for her condition can be provided.

Given her economic status, an appropriate rehabilitation center should

be chosen . One that will not cost the family too much since April has three

siblings, one of which is still going to school. An expensive rehabilitation

center would further pull down the family’s already unstable financial status.

VI. Evaluation and Implication of this Case Study to:

Nursing Practice
 87

In the nursing practice, it is vital that with the increasing number of

stressors in the environment and an easy access to drugs, addictive or not,

professions in the medical field are more prone to being a drug dependent due

to the easy access to medications. The nurse should know how to recognize

the signs and symptoms of drug dependence if ever they see one not only to

promote the integrity of their profession but also for the benefit of their

clients.

Nursing Education

Since most of the client’s significant others are directly affected with

the effects and social repercussions of the condition, it is important to learn

and understand this condition in order to impart adequate and understandable

information to them. Knowledge is important in order to effectively intervene

in the management of signs and symptoms in collaboration with reorientation

and pharmacotherapy.

Nursing Research

The human mind is a subtle and mysterious part of the human body;

cannot be adequately fathomed by the human intellect. Researchers may so

much as theorize as to the factors, signs and symptoms of substance abuse-

induced psychosis but the larger part of the condition lies largely unexplained.

It differs from person to person and affects the society in varied ways. This

nursing research aims to give us a peek of what it is like in April’s world not
 88

only for a more holistic care but also to help prevent another innocent life

wasted by illegal drugs.

VII. Bibliography

Davis, F.A. Taber’s Cyclopedic Medical Dictionary. California: 20th edition

Kozier, Barbara, et al. Fundamentals of Nursing: Concepts, Processes and

Practice. Philippines: Pearson Education South Asia Inc., 2004

Marieb, Elaine. Essentials of Human Anatomy and Physiology. Philippines:

Pearson Education South Asia Inc., 2004

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Shives, Rebeccca. Concepts of Psychiatric-Mental Health Nursing. Philippines:

Lippincott Williams ans Wilkins, 2002

Videbeck, Shiela. Psychiatric Mental Health Nursing. Philippines: Lippincott

Williams and Wilkins, 2002

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