II.

OBJECTIVES

General Objectives:

After two weeks of student nurse-resident interaction, the student nurse and the resident will be

able to gain knowledge about the resident's condition, show a positive attitude, and elevate

coping skills.

Student Nurse Objectives

Student Centered

After 8 hours of student nurse – resident interaction, the student nurse will be able to:

1. Have a thorough assessment of the client

2. Discuss the biological and psychological theories of the etiology of Alcohol-Induced

Psychosis

3. Identify the classical and clinical signs and symptoms of Alcohol-Induced Psychosis

4. Formulate nursing diagnoses and goals for the client

5. Intervene therapeutically in the client’s thought and behavioral disturbances

6. Evaluate the effectiveness of nursing actions designed for the client.

Resident Centered

After 8 hours of resident -student nurse interaction, the student nurse will be able to:

1. Build a trusting relationship with the student nurse

2. Verbalize feelings about student-nurse client interaction

3. Identify stressors in his life

4. State the importance of using adaptive coping mechanisms in dealing with stress

5. Participate actively in the therapeutic interventions rendered by the student nurse

III. NURSING ASSESSMENT

Patient’s Profile

Name: Mr. F.P.

Age: 50 years old

Sex: Male

Civil Status: Separated

Nationality: Filipino

Religion: Roman Catholic

Complaints: Psychosis (Alcohol-induced)

1.1. Family and Individual Information, Social and Health History

A case of Mr. F.P., a 50-year old male resident of Banaglaum Home, admitted on March

27, 2014. He had no known food and drug allergies. He claimed to have a hereditary familial

illness which was hypertension. The patient was originally admitted at MetroPsych and was

transferred to Banaglaum Home and was not discharged since then. The resident verbalized

that he was close with his father and older brother. He had 5 offspring with his wife but they

were already separated. He was a practicing Roman Catholic. He attended mass every Sunday.

The resident was admitted due to psychosis. He claimed that his admission was

voluntary. The resident was a retired policeman and he verbalized that his job stressed him out

since it was too demanding of his time and energy. He used to smoke cigarettes and drink

alcoholic beverages on a daily basis in order for him to cope up with the stress and problems in

his life. The resident's family noted of delusions and behavioral changes thus prompted the

admission.
1.2. Level of Growth and Development

1.2.1 Normal Development at Particular Stage

• Middle Adult

• ( 45-65 years old)

• Generativity vs. Stagnation

Physical Development

People who are under in this span of age have usually completed physical

growth. Maturational development is complete at this time with most systems operating

at peak efficiency. All systems of the body were functioning at peak efficiency.

Integumentary System

The skin had no pigmentation changes, rash or pruritus, bruising of bleeding,

nevi or moles, excessive dryness or sweating. The hair was gray in color, no dyes or

chemicals used, abundant hair growth, no lesions on scalp and baldness was minimal.

The head had no lesion or lumps, and the resident was not experiencing syncope and

vertigo. He had two ears, one on each side of the face. No tinnitus, discharges and

decreased hearing sensation. The nose was functioning at optimum level, no obstruction

and epistaxis. The neck had no swelling and limitations in movement. Breasts had no

lumps, no pain and no discharges.

Skeletal and Muscular System

No limitation to movement, no abnormalities. Strong and good range of motion.

Intact bone structure.

Cardiovascular System

Normal chest expansion. Heart rate and blood pressure levels were within

normal range.
Respiratory System

Oxygen supply and disposing carbon dioxide was in equilibrium. Clear breath

sounds and respiratory rate was within normal range.

Digestive System

Adequate food intake. Food was taken orally. Food was broken down normally.

Urinary System

Normal flow of urine. Kidneys were functioning properly and not damaged. Color

of urine was from light yellow to yellow.

Reproductive System

Normal male organs and parts. No inflammation, stitches or abnormalities

present.

Neurologic System

No hallucinations and illusions were noted. Stayed intact to reality. Normal

transmission of messages via the neurons and axons. Normal size of the lobes of

the brain and the spinal cord had no abnormalities.

1.2.2 The Ill Person at Particular Stage of the Resident

Health risk factors for a middle adult originate in the community, life style

changes and family history. Middle adults tend to ignore physical symptoms and

often postpone seeking heath care. A family history of a disease may put a

middle adult at risk for developing it, also the distinction of hereditary

disease/condition. Mr. F.P.'s psychosocial functioning was significantly

impaired by interaction of his illness and his methods of coping. The delusions

and disorganized behavior interfered with his functioning. His coping methods of

avoidant behavior toward tasks and interpersonal situations and the increase of
 soft symptoms to deal with stress in turn increased anxiety, negative cognitions,

and psychotic symptoms.

1.3. Diagnostic Tests

The resident has no recent diagnostic test.

1.4. Mental Status Examination

Name: Mr. F.P.

Age: 50 years old

Sex: Male

Civil Status: Separated

Complaints: Psychosis (Alcohol-induced)

Appearance

Mr. F.P. was a 50- year old male Filipino. He had an average build. The resident

was seated on a white plastic chair facing towards the student nurse. The resident had

showered and had worn a clean yellow shirt, a pair of red short pants, and a pair of

slippers. The resident's hair was neatly combed. He had no physical deformities or

visible scars.

Behavior

The resident maintained eye contact and he was cooperative and polite during

the interaction with the student nurse. He offered a seat to the student nurse. He was

alert and attentive to every spoken word of the student nurse. His gait and posture

were normal and the speed of his movement was neither too fast nor too slow.

Somehow, he displayed some aggressive behaviors when he was around other

residents or when he won a game of chess against the student nurse.

The resident spoke with an appropriate volume of the voice in a normal rate. His

voice became too loud when he was sharing something to the student nurse which he

might have found very amusing to him. The intonation of his speech was appropriate to

the expression of his words. He gave appropriate answers to the questions that were

asked by the student nurse. he spoke with clear articulation and initiated a conversation

with the student nurse and the other residents.

Implication

The resident displayed proper behavior and was accommodation to the student

nurse. He was polite and was able to communicate with the student nurse effectively.

With the resident's appearance, behavior, and communication, all goals seemed to be

achievable.