Hildegard Peplau’s Interpersonal Relations 101

Republic of the PhilippinesNORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGYOld Sagay, Sagay City, Negros Occidental(034)722-4120/www.nonescost.edu.ph

CERTIFICATE NUMBER: AJA12.0653

HILDEGARD PEPLAUS INTERPERSONAL RELATIONS THEORY IN ITS RELEVANCE INA BIPOLAR PATIENT

A CLINICAL RESEARCH PAPER

Presented to

The Faculty of the Graduate SchoolNORTHERN NEGROS STATE COLLEGE OF SCIENCE AND TECHNOLOGY Old Sagay, Sagay City, Negros Occidental

In Partial FulfillmentOf the Requirements for the DegreeMASTER in NURSING major inNURSING MANAGEMENT AND ADMINISTRATION

By

TIFFANY ALTEZA C. UNTAL, R.N.ACKNOWLEDGEMENT

This clinical research paper would not be accomplished without the assistant and encouragement, support and guidance of several people whom I am forever indebted with.

First I would like to thank God for bestowing me the blessings and a beautiful mind even if at times it might be such a wonderful mess. Without such Omnipotent Grace, none of these are possible.

To my ever-loving family, friends and dear mentors fortheir unyielding support upon my venture in finishing this paperI salute your ever steadfast confidence you have given medespite of my frailties and shortcomings upon accomplishing this task.

My deepest gratitude to the Negros Occidental Drug Rehabilitation Foundation, Inc. (NODRFI) staff especially to Dr. Ernesto A. Palanca and Ms. Juvy A. Pepello for allowing me to discover the struggles and beauty, triumph and despair as wellas the magnificence of the human mind that had been the source of hope and motivation of the restoration and inspire rehabilitation. Thus, the essential existence of the institution.

And lastly, I dedicate this paper as a tribute to the patient and to those who are suffering the same ailment. May this paper serve as a penchant of hope that all is not lost; anaffirmation that you have capabilities in determining the courseof your own destiny. Thank you for trusting me and sharing with me the fragile yet intricate longings, beautiful yet forlorn dreams and allowing me to impart and to take a glimpse in your battles with loneliness and despair. May you find your inner purpose that will motivate you to be a blessing in humankind and accept your condition as a gift rather than a curse, making most of lifes clashing ironies into magnificent symphony.TABLE OF CONTENTS

Page

Title Pagei Approval Sheetii Table of Contentsiii List of Tablesiv List of Figuresv

Chapter IIntroduction

Background of the Study1Statement of the Problem3Significance of the Study4

Chapter IIReview of Related Literature

Conceptual Framework22Assumption26Definition of Terms26

Chapter IIIApplication of Nursing Process

Findings Conclusion Recommendation References Appendices Patients Profile28Clinical History28Patients Anamnesis29NPI38MethodologyAssessment Tool43Scoring and Interpretation46The Nursing ProcessAssessment Phase43Planning Phase48Implementation Phase54Evaluation Phase58

- Appendix A: Letters- Appendix B: Assessment Tool- Appendix C. NCP-List of Tables

TablePage

1Initial Assessment Score45

2Nursing Care Plan48

3Monitoring Chart49

4Final Assessment Score56

5Mean Difference Between56The Initial and Final Assessment

List of Figures

FiguresPage

1Schematic Diagram of Peplaus27Interpersonal Relations Theory: Conceptual Framework

2Evaluative Scale46

3Initial Evaluative Scale of Mean46

4Final Evaluative Scale of Mean47

5Comparative Level of Loneliness Tendency57Between The Initial and Final AssessmentResult

7Comparative Level of Initial and57Final Assessment in ChartCHAPTER I INTRODUCTIONMoods are typically transient things that shift from moment to moment or day to day. While people's moods rise and fall,most of it never become that extreme or uncontrollable. As depressed as an average person might get, it won't take too much for them to recover and start feeling better. Similarly, happy and excited moods are not easily sustainable either, and tend to regress back to a sort of average mood.At times, emotions could stir an artistic drive that creates a marvelous passion. Yet, sometimes it is deeply rooted on a more serious pathology. It generates a fire that potentiates an individual to be motivated or it personifies a force to led life to a deeper essence. However to certainpeople, it is the same fire that burns.Taming emotions takes a

bit of mastery; but for them, it is already a major life battle wherein their sanity priced the cost.We all have monsters inside our head; Although a few lived by their own demons and can no longer control their own sense of self-integrity. These fellows need more attention; their eccentricities and outbursts already a call for help. They could be a stranger, a passerby, a neighbor, a friend, a family, or it might had already been you.16

Society itself held the stigma and biases to this persons instead of understanding and support. These individuals actually scream for help within their own inner dilemma. And if these submerged implosions and rage be not sufficed to induce violence with themselves, it eventually explodes into a violence toward others.This clinical paper had been brought forth to determine the effectiveness of Nurse-Patient interaction and Nursing intervention utilizing Hildegard Peplaus InterpersonalRelations Theory wherein significant roles of a nurs is being acted in promotion if not for the full-recovery, at least the rehabilitation or even just the alleviation of symptoms characterized by these patients having mental illness as characterized in the change of attitude and disease adaptation by helping them recover self-integrity in the discernment that they are more than just the symptoms of their illness.

Statement of the Problem

Is there a change in the level of loneliness tendency when Peplaus Interpersonal Relations Theory is utilized together with the nursing process in the management of Bipolar.

Significance of the Study

Patient. That he/she would gradually identify the root of his/her own disorder and imbue learning while encourage awareness and hope to recovery and progressivelybe the inspiration and becoming an advocate to the youth unto which act as a guide not to led astray.Family. That each member will cultivate awareness and

instead of blame, anger and despair nurture understanding, patience, compassion instead and inner growth in understanding the patient and serve as a strong support system to the recovery of the patient.Health Provider/Rehabilitation Staff. That it would instill

resonance of learning and progression in profession not

only as a mental health nurse but by applying the theory in each patients that he/she would come across into promoting health, imparting social deliverance and render baggage unburdening towards the holistic recovery of patients. And Health and Social Programs for children, youth and families should take on a forward- thinking and holistic approach; services and programs should be available. Community. That the community would gradually understand and

have a grasp of knowledge concerning substance abuse and drug addiction, perception of the mentally deranged as well

of those who had been rehabilitated. The study also strive to reach out awareness to the cause, effect and prevention of factors that would lead to rehabilitation and not just a casual cultural clich that each member of the societycould partake in collaboration into the nurses different role to further advance recovery of the patients and gradually to the interaction of the patient post rehabilitation.

Future researchers.The results of this study will serve

as a reference material for those who would like to conduct further study on similar topics.

CHAPTER II

REVIEW OF RELATED LITERATURE

In contrast to people who experience normal mood fluctuations are people who have Bipolar Disorder. People with bipolar disorder experience extreme and abnormal mood swings that stick around for prolonged periods, cause severe psychological distress, and interfere with normal functioning.Most people can't stay too depressed or too happy for any

length of time. A study suggests that emotional pain lasts for

12 minutes, anything longer than that is considered to be self- inflicted as it shows people would rather inflict pain on themselves than spend 15 minutes with their own thoughts (Sheridan, 2014).Bipolar Disorder (also known as Manic-Depression, or

sometimes Bipolar Affective Disorder), is a category of serious mood disorder that causes people to swing between extreme, severe and typically sustained mood states which deeply affect their energy levels, attitudes, behavior and general ability to function. Bipolar mood swings can damage relationships, impair job or school performance, and even result in suicide. Family and friends as well as affected people often become frustrated and upset over the severity of bipolar mood swings.Bipolar moods swing between 'up' states and 'down' states. Bipolar 'up' states are called Mania, while bipolar 'down'

states are called Depression. Mania is characterized by a euphoric (joyful, energetic) mood, hyper-activity, a positive, expansive outlook on life, an inflated sense of self-esteem or grandiosity (a hyper-inflated sense of self-esteem), and a sense that most anything is possible.Depression is, more or less, the opposite mood state from

mania. Depression is characterized by feelings of lethargy and lack of energy, a negative outlook on life, low or non-existent self-esteem and self-worth, and a sense that nothing is possible. Depressed individuals tend to lose interest in thingsthat used to give them pleasure and enjoyment (such as sex, food

or the company of other people). They may sleep too much or too little. Regardless of how much sleep they actually get, they tend to complain about feeling constantly tired and fatigued. Their mood tends to be dysphoric (e.g., distressed, negative, unhappy), although they may experience dysphoria in different ways. Such negative feeling states help depressed people lose confidence in their abilities, become pessimistic about their futures, and (sometimes) conclude that life is no longer worth living.Interpersonal theory and interventions are useful for patients with a wide variety of diagnostic labels, including schizophrenia, depression, mood disorders, borderline personality disorders, and mild mental retardation. These

interventions are useful both in one-to-one therapeutic relationships and milieu interventions. The theory and interventions provide an effective adjunct for psychopharmacology and psychiatric rehabilitation, particularly with people who have complex behavioral problems refractory to psychopharmacological intervention.Cacioppo and Hawkley (2010) have hypothesized that lonely people are hyper-vigilant to social threat linking this bias specifically to threats of social rejection or social exclusion. This could mean that lonely people in their everyday lives (1) fail to make accurate appraisals of social events, such thatthey misinterpret social events negatively, but also (2) that they have visual attention biases, such that they are on the lookout for negative social events so that they can avoid them and protect themselves against psychological pain.According to the Canadian Nurses Association, psychiatric

nurses must be knowledgeable in the areas of biological and psychological theories of mental health and mental illness, psychotherapy, substance abuse, care of populations at risk, the community as a therapeutic milieu, cultural and spiritual implications of nursing care, psychopharmacology and documentation specific to the care of the mentally ill. Skill competency stresses comprehensive bio-psychosocial assessment, interdisciplinary collaboration, identification and coordination

of resources for offenders and families, the use of psychiatric diagnostic classification systems, therapeutic communication, establishing therapeutic relationships, therapeutic use of self, psycho-education with clients and administering and monitoring psychopharmacologic agents.Recovery has been defined as a process of healing and

transformation that results in the ability to achieve full potential in living a meaningful life (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). It includes healing processes such as self-direction, individualized and person-centered care, empowerment, holistic recovery, strengths-based care, mutuality, respect, and responsibility (SAMHSA, 2013). Person (patient)-centeredness is one of multiple processes that support recovery.Psychiatric nursing practice is rooted in the healing power of the interpersonal nurse-patient relationship, as described by Hildegard Peplau (Howk, 2012), an early leader in thedevelopment of modern psychiatric nursing. Nurses generally agree that nursing practice should be patient centered in the sense that effective working relationships are formed with patients to provide nursing care that incorporates an understanding of the patients perspective. Beyond patient- centeredness, psychiatric nurses view nursing care as helping patients work through mental health concerns that are marked by

anxiety and non-adaptive coping behaviors, to achieve mental health recovery.Dr. Hildegard Peplau introduced an interpersonal relations paradigm for the study and practice of nursing in the late 1940s and early 1950s (Rust, 2012). Her theory is one of the early Nursing theories, published in 1952. The paradigm evolved from her work with H. Sullivan, E. Fromm, F. Fromm-Reichmann, other eminent clinicians, and her experience working with seriously mentally ill patients in public and private psychiatric hospitals. Her Interpersonal Relations Theory has had particular relevance and usefulness in understanding and intervening to reduce symptoms, re-establish relatedness, restore a sense of self-identity, improve function, and promote health.Peplau's Interpersonal Relations Theory describes psychiatric nursing roles in terms of the position which the nurse assumes during the various phases of the nurse-client relationship. The client is defined as an individual rather than a community or group. Dr. Peplau's scope of influence goes far beyond the field of psychiatric mental health nursing. She advanced nursing professional, educational, and practice standards and stressed the importance of professional self- regulation through credentialing. For her, the key question was: What do nurses know and how do they use that knowledge to benefit people? (Rust, 2012).

The nurse-patient relationship consists of four steps (orientation, identification, development and conclusion). In these steps nurse could have the role of foreign, reliable person, teacher, guide in nursing care, substitute and consultant. Nurse-patient relationship is influenced by psychobiological experiences (needs, frustrations, conflicts and anxiety) which need dynamism. Peplau thinks that Nursing care is an important opportunity for nurse because she can help patient to complete the infancy psychological tasks (learning to rely on other people, learning to show satisfaction, self-identifying, and developing ability in sharing) if these are not completed. For these reasons Nursing, by Peplau, is a maturation strength of civilization (Dussault, 2014).As many as 5 million adolescents suffer from clinical depression, but according to a 2009 study, an estimated 70 percent are undiagnosed and dont receive any form of treatment. Without treatment, a depressed teen may turn to alcohol or drugs to escape their feelings of helplessness or to help them feelnormal. Unfortunately, drug and alcohol use only worsens

depression symptoms (Drug Abuse and Depression in Teens, 2010).

Adolescence, by definition, is a time of risk takingbrain imaging has shown us that teens are hard-wired to take more chances as the parts of the brain that generate ideas and make

decisions continue to mature and grow. (Drug Abuse and

Depression in Teens, 2010).

Many aspects of this phase of brain development are beneficial, allowing teens to be creative and flexible in their thinking, and helping them to hone in on the pursuits they are passionate about. On the flip side, this risk-taking phase of development also makes teens vulnerable in ways that have the potential for harm and long-term problems.Interpersonal theory and interventions are useful for patients with a wide variety of diagnostic labels, including schizophrenia, depression, mood disorders, borderlinepersonality disorders, and mild mental retardation (Rust, 2012). These interventions are useful both in one-to-one therapeutic relationships and milieu interventions. The theory and interventions provide an effective adjunct forpsychopharmacology and psychiatric rehabilitation, particularly

with people who have complex behavioral problems refractory to psychopharmacological intervention.Bipolar disorder, also known by its classic name "manic depression," is a mental disorder that is characterized by serious mood swings. A person with bipolar disorder experiences alternating highs (what clinicians call mania) and lows (also known as depression). Both the manic and depressive periods can be brief, from just a few hours to a few days, or

longer, lasting up to several weeks or even months (Cacioppo, et al.2013).A manic episode is characterized by extreme happiness, extreme irritability, hyperactivity, little need for sleep and/or racing thoughts, which may lead to rapid speech. A depressive episode is characterized by extreme sadness, a lack of energy or interest in things, an inability to enjoy normally pleasurable activities and feelings of helplessness andhopelessness. On average, someone with bipolar disorder may have up to three years of normal mood between episodes of mania or depression.Bipolar disorder changes the course of your life, but it doesnt mean you cant do great things, said Holly Swartz, M.D., associate professor of psychiatry at the University ofPittsburgh School of Medicine and Western Psychiatric Institute

and Clinic in Pittsburgh (Cornwell, 2010). With a combination of medication, psychotherapy and self-management strategies, individuals with bipolar disorder can lead productive,successful lives. If left untreated, bipolar disorder can wreak

havoc on a persons life. It requires both medical treatment and psychotherapy. Having a support system is critical in successfully managing bipolar disorder.Peplaus (Rust, 2012) theoretical model of the nurse-

patient relationship emphasized mutuality as an essential

process for an effective nurse-patient working relationship to foster growth in constructive coping responses toward the goal of recovery. Mutuality is characterized by both individuals sharing information and collaborating to make decisions in relation to jointly agreed-on goals. The concept of mutualityhas been reframed and extended in the concept of shared decision

making that involve decision making about therapeutic options.

One of the most common side effects of bipolar disorder is an intense and inexplicable sense of loneliness. This mental state causes severe physical and psychological consequences for people who fail to take adequate precautions or interventions to avoid ongoing complications.Loneliness is a universal emotional and psychological experience. Loneliness is also seen as a normal experience that leads individual to achieve deeper self-awareness, a time to be creative, and an opportunity to attain self-fulfilment and to explore meaning of life. Loneliness is also a condition of human life, an experience of humanizing which enables the person to sustain, extend, and deepen his/her humanity. According to Weiss (2011), loneliness is caused not by being alone but beingwithout some definite needed relationship or set of relationships. Loneliness appears always to be a response to the absence of some particular relational provision, such as

deficits in the relational provisions involved in social support.Researchers have indicated that adolescents experience more loneliness than any other age groups. Late adolescence and early adulthood (i.e., university age) are especially high risk for experiencing loneliness. Lack of social and emotional supportmay lead to the experience of social and emotional loneliness.

For the most part, loneliness research has tended to focus on individual factors, that is, either on personality factors or lack of social contacts.The degree, frequency, and quality of a person's loneliness

will be a function, among other things, of the society in which he or she lives. The UCLA Loneliness Scale is a commonly used measure of loneliness. Its name derives from its having been developed at the University of California, Los Angeles (UCLA).It was first published in 1978 by Russell, D., Peplau, L.A., and

Ferguson, M.L., and was revised in 1980 and 1996.Developer Daniel Russell has expressed concern that publication of the scale could skew responses. The UCLA Loneliness Scale was developed to assess subjective feelings of loneliness or social isolation.Items for the original version of the scale were based on statements used by lonely individuals to describe feelings of loneliness.The questions were all worded in a negative or lonely direction, with individuals indicating how

often they felt the way described on a four point scale that ranged from never to often.Hildegard Peplau (Forchuk,2014) a legendary nurse theorist, introduced a theory of interpersonal relationships in nursing. She argued that the purpose of the nurse-client relationship is to provide effective nursing care leading to health promotionand maintenance. Within the nurse-client relationship, the nurse

adopts one or more of six helping roles when providing care: stranger, resource person, teacher, leader, surrogate, and counselor. A seventh role, technical expert, was added later (Stockman, 2012). Although the seventh role was not included in Peplaus original theory, all the roles will be referred to as Peplaus helping roles in this article as is customary in the nursing literature.The stranger role occurs when the nurse and the client

first meet and become acquainted. They begin the relationship as strangers, each with preconceived expectations for the first encounter. The goal of the nurse is to establish therelationship and build trust with the client. Peplau (Rust,

2012) believed that compassionate verbal and nonverbal communication, a respectful approach, and nonjudgmental behavior are essential to this role. Successful implementation of the stranger role is the foundation for development of a therapeutic

relationship and a necessary condition for the establishment of the other roles.In the resource person role, the nurse provides specific factual health information in response to a clients questions and interprets the clinical plan of care (Rust, 2012). Essential to this role are expert professional knowledge, the ability to deliver information in a sensitive manner, and critical thinking skills needed to process the clients questions and offer a therapeutic response.Assisting the client to attain knowledge to improve health is the primary goal of the teacher role (Forchuk et al., 2013). This process may be formal, such as providing detailed instructions for individuals or conducting training sessions for groups to teach a health-related behavior, or the process may be informal, such as modeling patterns of health and wellness inthe therapeutic relationship.

The leadership role involves collaboration between the nurse and the client to meet desired treatment goals. The nurse offers guidance, direction, and support to promote the clients active participation in maintaining his or her health. The goal of the nurse is to help the client accept increased responsibility for the plan of care (Rust, 2012).In the surrogate role, the nurse functions as an advocate

or a substitute for another human being who is well known to the

client, such as a parent, sibling, other relative, friend, or teacher (Rust, 2012). Through this process a client may unconsciously transfer behaviors or emotions that are connected to a significant other onto the nurse. The nurse addresses this reaction and assists clients to recognize the differences as well as similarities between themselves and the other.In the counselor role, the nurse encourages the client to explore his or her current situation or presenting problem. The nurse must be aware that such exploration often engenders anxiety and, therefore, must facilitate an atmosphere that is conducive for the client to safely express his or her concerns. To successfully implement the counseling role, the nurse must demonstrate active listening skills, apply therapeutic communication techniques, provide guidance and support in the process of self-discovery, and maintain professional boundaries and self-awareness (Forchuk et al., 2013)Although Peplau (Rust, 2012) did not include the technical expert role in her original work, it is now considered to be one of the primary helping roles of the nurse-client relationship.As a technical expert, the nurse demonstrates technical skills to perform nursing care. The technical expert role includes physical assessment and interventions and the use of equipment, such as intravenous pumps, blood pressure cuffs, and ventilators.

The implementation of the helping roles (Rust, 2012) has been described in a number of settings, including psychiatric and mental health, surgical, and palliative care. Peplau discusses major features of the theory of interpersonal relations. She describes her theory as among the most useful to apply during nursing practice in order to understand nurse- patient interactive phenomena. Peplau addresses how she derived constructs from clinical data and identified their congruence with nursing practice. She further addresses the specificconcepts of her theory and their relations, and specific uses of the theory in practice.Peplau went on to form an interpersonal model emphasizing the need for a partnership between nurse and client as opposed to the client passively receiving treatment (and the nurse passively acting out doctor's orders). The essence of Peplau's theories is the creation of a shared experience thus building mutuality on both part of the patient and the health provider. Nurses, she thought, could facilitate this through observation, description, formulation, interpretation, validation, and intervention (Fowler, 2011).Roles of nurse

Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting climate that builds trust.

Teacher: who imparts knowledge in reference to a need or interestResource Person : one who provides a specific needed

information that aids in the understanding of a problem or new situationCounselors : helps to understand and integrate the meaning

of current life circumstances ,provides guidance and encouragement to make changesSurrogate: helps to clarify domains of dependence

interdependence and independence and acts on clients behalf as an advocate.Leader : helps client assume maximum responsibility for

meeting treatment goals in a mutually satisfying way

Additional Roles include: Technical expert, Consultant, Health teacher, Tutor, Socializing agent, Safety agent, Manager of environment, Mediator, Administrator, Recorder observer, Researcher.Phases of interpersonal relationship (Taylor, 2011)

Identified four sequential phases in the interpersonal relationship:1.Orientation

2.Identification

3.Exploitation

4.Resolution

I. Orientation phase

Problem defining phase

Starts when client meets nurse as stranger

Defining problem and deciding type of service needed

Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiencesNurse responds, explains roles to client, helps to identify problems and to use available resources and servicesII. Identification phase

Selection of appropriate professional assistance

Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessnessIII. Exploitation phase

Use of professional assistance for problem solving alternativesAdvantages of services are used is based on the needs and interests of the patientsIndividual feels as an integral part of the helping environmentThey may make minor requests or attention getting techniques

The principles of interview techniques must be used in order to explore, understand and adequately deal with the underlying problemPatient may fluctuates on independence

Nurse must be aware about the various phases of communicationNurse aids the patient in exploiting all avenues of help and progress is made towards the final stepIV. Resolution phase

Termination of professional relationship

The patients needs have already been met by the collaborative effect of patient and nurseNow they need to terminate their therapeutic relationship and dissolve the links between them.Sometimes may be difficult for both as psychological dependence persistsPatient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals.

Conceptual Framework

Peplau (Rust, 2012) defines man as an organism that strives in its own way to reduce tension generated by needs. The client is an individual with a felt need. Healthcare professionals are considered to be any individuals who provide services to promote the physical and mental well-being of others and to care for those who are ill or injured. Peplau (Rust,2012) described nursing as "a significant, therapeutic,

interpersonal process. It functions co-operatively with other human processes that make health possible for individuals in communities. Nursing is an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living". Lack of growth, for whatever reason, implies impaired health in the individual and basic human needs must be met if a healthy state is to be achieved and maintained (Forchuk,2014).The relationship of nurse and patient is influential in the outcome for the patient; People may assume a number of roles and have the capacity for empathy in relationships (Rust, 2012); People tend to behave in ways which have worked in the past when faced with a crisis (Forchuk,2014); Anxiety and tension arise from unmet or conflicting needs, and the energy which arises may

be harnessed into positive means for defining, understanding and meeting the problem at hand.In 1952, Peplau published her Theory of Interpersonal Relations that was influenced by Henry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elgar Miller (Rust, 2012).Her theory emphasized the nurse-client relationship as the

foundation of nursing practice. It gave emphasis on the give- and-take of nurse-client relationships that was seen by many as revolutionary. Peplau went on to form an interpersonal model emphasizing the need for a partnership between nurse and client as opposed to the client passively receiving treatment and the nurse passively acting out doctors orders.The four components of the theory are: person, which is a

developing organism that tries to reduce anxiety caused by

needs; environment, which consists of existing forces outside of the person, and put in the context of culture; health, which isa word symbol that implies forward movement of personality

and nursing, which is a significant therapeutic interpersonal process that functions cooperatively with other human process that make health possible for individuals in communities.The nurse patient relationship is characterized by a number

of overlapping phases with a number of therapeutic tasks or goals to be accomplished. During each phase the patient

expresses needs which find expression and require intervention in unique ways.Health is defined as a word symbol that implies forward

movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living (Rust, 2012)Although Peplau does not directly address

society/environment, she does encourage the nurse to consider the patients culture and mores when the patient adjusts to hospital routine. Hildegard Peplau considers nursing to be a significant, therapeutic, interpersonal process (Rust, 2012). She defines it as a human relationship between an individual who is sick, or in need of health services, and a nurse specially educated to recognize and to respond to the need for help.Therapeutic nurse-client relationship. A professional and

planned relationship between client and nurse that focuses on the clients needs, feelings, problems, and ideas.Nursing involves interaction between two or more individuals with a common goal. The attainment of this goal, or any goal, is achieved through a series of steps following a sequential pattern.The nursing model identifies four sequential phases in the

interpersonal relationship: orientation, identification,

exploitation, and resolution.

Anxiety was defined as the initial response to a psychic threat.

The phases of the therapeutic nurse-client are highly comparable to the nursing process making it vastly applicable. Assessment coincides with the orientation phase; nursing diagnosis and planning with the identification phase; implementation as to the exploitation phase; and lastly, evaluation with the resolution phase.Four Phases of the therapeutic nurse-patient relationship:

1. The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions.2. The identification phase begins when the client works

interdependently with the nurse, expresses feelings, and begins to feel stronger.3. In the exploitation phase, the client makes full use of the

services offered.

4. In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship ends.

Assumption

Nurse and patient can interact. Peplau stresses that both the patient and nurse mature as the result of the therapeutic interaction. Communication and interviewing skills remain fundamental nursing tools. Peplau believed that nurses must clearly understand themselves to promote their clients growth and to avoid limiting clients choices to those that nurses value. It is assumed that the nurse will utilize Hildegard Peplaus Interpersonal Relations Theory in the care of the bipolar patient in response to UCLA (University of California, Los Angeles) Loneliness Scale,in determining patients level of tendency towards loneliness.

Definition of Terms

Important terms in this study were defined conceptually and operationally:Bipolar. Formerly called manic depression, is a mental illness

that brings severe high and low moods and changes in sleep, energy, thinking, and behavior.Environment. Existing forces outside the organism and in the

context of culture

Health. A word symbol that implies forward movement of personality and other ongoing human processes in the direction

of creative, constructive, productive, personal and community living.Loneliness. A normal experience that leads individual to achieve

deeper self-awareness, a time to be creative, and an opportunity to attain self-fulfilment and to explore meaning of life. Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that makehealth possible for individuals in communities.

Person. A developing organism that tries to reduce anxiety caused by needs.UCLA Loneliness Scale. A commonly used measure of loneliness

derives from its having been developed at the University of California, Los Angeles (UCLA) to assess subjective feelings of loneliness or social isolation. It was first published in 1978 by Russell, D., Peplau, L.A., and Ferguson, M.L., and wasrevised in 1980 and 1996. This 20-item measure has reported high

internal consistency and good evidence of construct, concurrent, and discriminant validity (Hagerty et al., 1996; Russel et al.,1980). Items were assessed on a four-point Likert scale ranging from 1 (never) to 4 (always), with a higher score indicating a greater degree of loneliness. The internal consistency of the Loneliness scale was 0.86.

5

Figure 1. Conceptual Framework:

Interpersonal Relations Theory

Low SelfEsteem RESOLUTION PHASE

PATIENT

Socially Withdrawn

Severe TendencyTowards Loneliness EXPLOITATION PHASE

IDENTIFICATION PHASE ORIENTATIONPHASE

NursePatientRelationship

Nurse as a:

v Strangerv Teacherv ResourcePersonv Counselorv Surrogatev Leader

WellRounded Person with Restored Socialization, Confidence, SelfIntegrity and Effective Coping Mechanism.

PATIENTA Schematic Diagram Depicting the Relationship of Utilizing the Effectiveness of Peplaus InterpersonalRelations Theory practicing the Nurses Roles throughout the phases towards the success of patients Rehabilitation.

35

CHAPTER III

Application of the Nursing Theory

Client Profile

Name: P. U.

Age: 16 years old

Sex: Male

Birthday: July 7, 1998

Address: Esteban Subdivision, Pulupandan, Negros Occ. Civil Status: ChildEducational Attainment: 4th year High School Student

Religion: Roman Catholic

History of the Present Illness

The patient had manifest first depression upon returning home from school one day having ambivalent expression and had his packed lunch untouched. Since then, he consecutively had bouts of sudden crying of getting restless and mad for no apparent reason. He had been skipping classes and found to be with peers who are having recent substance abuse records. Hewould escape their house at the middle of the night and suddenly

resort to being a loner and complain having insomnia.

The patient then had been under the care of Dr. Charibel Escandelor on June 2012. He exacerbated again late last year (2013) and is presently still very symptomatic showing both psychosis band very manic symptoms. His folks have difficulty keeping him at home and ensuring he takes his medicines. He recently had a negative (-) drug test and has no known illness. On March 24, 2014 he had been admitted at the Negros Occidental Drug Rehabilitation Foundation, Inc. and and was discharged June6, 2014 provided being still on strict medication and a monthly

follow up consultation with Dr. Escandelor and the Psychiatrist of the said institution to finish his last year on high school.

Patients Anamnesis

FREUDsERIKSONsPATIENT ANAMNESISOnce cell differentiation is mostly complete, the embryo enters the next stage and becomes a fetus.The early body systems and structures established in the embryonic stage continue to develop. The neural tube develops into brain and spinal cord and neurons form. Sex organ begins to appear during the third month of gestation. The fetus continues togrow in both weight and length, although the majority of the physical growth occurs in the latter stages of pregnancy.

A. Prenatal

v Pregnancy was planned

v Mother had pre-natal

v Mother is in good conditionv Mother has no vices and is not into drugsv No illnesses during pregnancyStage 1. Begins from the onset of true labor lasts until the cervix is completely dilated in 10cm.Stage 2. Continues after the cervix

has dilated to 10cm until the delivery of babyStage 3. Delivery of the placenta

B. Delivery

v The child was born at The Riverside Hospital, BacolodCity

v Normal DeliveryC. Oral Stage

(0-1 year old)

Libido isInfancy Period

(0-1 year old) Trust V.v Mother is the most significant personv Father is a seaman

focused on the mouthIndividual may be frustrated by having to wait onanother person, being dependent on another person,Mistrustand is absent at times since on board while the child is growing upv Mother is always at the patients sidev Patient grew in rural areav He has 5 siblings (2 boys,3 girls) being the 4th child in the familyv D. Anal StageToddler Period Autonomy Vs, Shame andDoubtv Patient was toilet trained by mother and sometimes yaya in the toiletv Patient responded positively with the trainingv Completed immunizationv Patient did not experience any physical crueltyv Patient was breastfed until weaned during2-3 years old while transitioned with bottle-feeding and solid foods during 1

year oldE. Phallic Stage (3-6 years old)Pre-School Period (3-6 years old) Initiative Vs.Guiltv Entered the school as a sit in with older brother since 3 years old and startedformal schooling the next yearv More close relationship to the mother since the father is working abroadv Patient is active at school being a cub scout and always volunteering forroles in every school activitiesF. Latent Stage (6-12 years old)School Age

(6-12 years old) Industry Vs.Inferiorityv Being active at school while joining the campus bandv Likes to play football and enjoy being with peersG. Genital Stage (12-18 years old Above)Adolescence

(12-18 years old) Intimacy Vs.Isolationv Started to try smoking cigarettesv Peer pressures

v Became a computer addictv Being hooked with RPG

games, had riot with

co-players and experienced having income solely on bidding game characters and items via netv Cellphone confiscated once at schoolbecause of porn- viewingvSkipping school hours and playing games on computer shopsv Always reprimanded being leader of the mischief in class

Summary of Patients Precipitating Factors:

v Peer pressure

v Insomnia

v Low Self-Esteem

v Being transferred to private school to be disciplinedv Almost always being pressured by the two older brother when there are shortcomings or misbehaviorv Strong personality of the mother and quite distant relationship in contrast to earlier version of maternal imagev No outlet at home nor in friends

v Stress in school transition and academy workloads

v Reports being bullied at school

v Addiction in computer began

Health History

A. History of PresentIllness

The patient then had been under the care of Dr. Charibel Escandelor on June 2012. He exacerbated again late last year (2013) and is presently still very symptomatic showing both psychosis band very manic symptoms. His folks have difficulty keeping him athome and ensuring he takes his medicines. He recently had a negative (-) drug test and has no known illness. On March 24, 2014 he had been admitted at the Negros Occidental Drug Rehabilitation Foundation, Inc. andand was discharged June 6, 2014 provided being still on strict medication and a monthly follow up

consultation with Dr. Escandelor and the Psychiatrist of the said institution to finish his last year on high school.B. Past Health History

a. Childhood Illness

The patient had no known childhood illness. b. Past HospitalizationThe patient had once been admitted at The

Doctors Hospital on 2010 due to Dengue. c. Serious Illness/Chronic IllnessSo far the most serious illness that had

been diagnosed with the patient is having a bipolar disorder diagnosed during 2012 which he had been managed with medication to the present while having monthly and now, adjusted to every 3 months visit to the Psychiatrist.d. Previous Surgery

The patient had only done circumcision procedure during earlier years and no previous surgery done.C. Family History

Both sides of the family had one or two distant relatives having nervous breakdown.D. MSE PROPER

1. General Appearance

The patient is well-groomed and sometimes being too conscious of appearance. He likes to wear fit but comfortable clothes and presently argue to resist haircut that is too long for a school prescribed haircut.2. Characteristic of Speech

The patient talks in a well-modulated voice, speaks spontaneously and can express self. Patient

sometimes stutters and stammers in prolonged conversation and fast-paced discussions3. Mood and Affect

Patients is always on ambivalent expression except when watching favorite anime that transforms him also into being animate and charged with motivation and positive disposition.4. Form of Thought

The patient has a history of auditory hallucinations esp. during the time of insomnia at the first phase of his emerging symptoms. He also have illusions once being a part of a powerful force and the delusion of grandeur being a special being, all-knowing and all-seeing creature.

5. Sensorium Function

v ORIENTATION

10 Khans Questions(When he was still admitted):

a. What is the name of this institution?

>> Rehab.

b. Where is it located?

>> Victorias.

c. What day of the week is today?

>> My day.. judgment day.

d. What is the month now?

>> March eh!

e. What is the year now?

>> 2014..

f. How old are you?

>> 15 kabos la ko ka intra the Voice

Audition

g. When were you born?

>> July 7, 1998

h. Where were you born?

>> Hospital sa Bacolod.

i. Who is the president now?

>> ..si P-noy ah.

j. Who is the president before?

>> :.. si Gloria. GMA

Evaluation:

The patient is oriented to person,time, place and situational orientation, though he had answered sarcastically the day of the week. Patient answered 9 out of 10 Khans question correctly, thus patient has mild brain organic syndrome. He had a sense regarding of his surroundings and congruence ofhis response.

Prognosis

FactorsGoodPoorI.Onset of Illness

A. Early 20 and above 40

B. Between 20 and 40

II.Education Attainment

A. Highschool

B. College

III. Sex

A. Male

B. Female

IV.History of Present Illness

A. Familial

B. None

V.History of Admission

A. Chronic

B. Acute

VI.Socio-Economic Status

A. Poor

B. Rich

VII. Family Support

A. With Family Support

B. Without Family Support

VIII.Pre- Morbid

Personality A. Introvert B. Extrovert C. Ambivert

IX.Compliance to Medication

A. With Compliance

B. Without Compliance

Evaluation:

Patient overall has a good prognosis of his current condition since the result of the evaluation shows 5 out of 9. Having 4 negative or bad outcomes that can be wired easily in patients good compliance to medication and treatment regimen so there will be no exacerbation symptoms.

Nurse-Patient Interaction (NPI)

Nurse-Patient Interaction (NPI)Day 1 11/24/2014NurseInteractionPatientInteractionNurse InferencePatientInference Sir good morning, ako gali imo nurse subong.Good morning manGiving information To have formal introduction to the patientSmiles and responds wellKamusta man matyag mo subong sir?Ok lang.Encouraging description To let him express his emotions on that certain timeSmiles and focuses more on the interaction.Ano sir ang rason ngaa na rehab ka man?Nag padungolabi mo. Takan sila sakun pasaway dan.Exploring To know if he is open and knows the reason of his admission to the institutionLooks shyly and slightly withdrawnAno nga padungol na sir?Ga mauy ko bi.. ga panigarilyo kag kis a tilaw2 man..Focusing Concentrating on asingle pointSlightly hesitant to confide some informationAno man na ang natilawan nyo sir?Marijuana pero kis-a lang to ya. Sigarilyopa gid kagpahubog e.Probing Persistent questioning of the clientOpen gesture and lightly respond to the question

Nurse-Patient Interaction (NPI)Day 2 11/25/2014NurseInteractionPatientInteractionNurse InferencePatientInferenceGood morning sir!Dawbusy subongsir aw..indi gid man a. na testingan ko lang liwat himu pispisBroad Opening Allowing the client to take initiative in introducing the topicEncouraging description To understand what he is doingBusy doing something but openly respond when approachedAno nasiya nahimomo sir? Daw ga concentrate ka gid aw?Ahh activity ni namonkagina pi-ud2x papelorigami.

Open gesture and demonstratepaper origami making of a birdBaw.. kasagadgali sa imo sir bha..Indi mangid a.Giving recognition To give acknowledgement andappreciationSmilingHappyNag enjoy ka gid gali ka gina sa activitynyo sir?Huo. Indi gid man gali budlay.Encouraging expression To let him express emotionsSmiling and enjoying what he is doingTe anhonmo na dayun sir?I-display ni kuno namon sa table didto karun huh, pa nami2 a.Formulating a plan of action Asking theclient toconsider what plans he is consideringShows enthusiasm

Nurse-Patient Interaction (NPI)Day 3 11/26/2014NurseInteractionPatientInteractionNurse InferencePatientInferenceGood morning sir. Updan ta lang ka di anay sir subong a.Pwede gid a.Offering Self Making oneself availableOpen gesture; Responds wellSilence Encourage him to express feelings while proving him time to organize thoughtsRemains calm but quite distantKadalum gid sang napanumdom ta sir aw?(smiles gently).. wala gid man a.Encouraging expression To let him expressemotionsSomewhat hesitantBasi may gusto ka ishare sir..(smiles)Suggesting collaboration To let the patient open up and identify problems while growing emotionally with others.Still distantSige sir a.. indi ka pa guro readymag open up sharing..Dason lang nurse a.Translating into feelings Voicing what thepatient has hintedSmiles and attentive

Nurse-Patient Interaction (NPI)Day 4 11/27/2014NurseInteractionPatientInteractionNurse InferencePatientInferenceHi sir. Nagkwa ka gali test bag o lang. Huo. Pa kwa ko nila Ms. DaphneBroad Opening Allowing the patient to take initiative in introducing the topicResponds wellTe kamusta ang test sir?Hapos lang man a. Damu galing answeran. Kapoy.Encouraging description of perceptions Asking client toverbalize what heperceivesOpens with the topicDaw parehaslang nagkwa ka exam sa skwelahan gali.Kapoy e. ga liguy gani.. heheEncourage Comparison Asking that similarities anddifferences benotedAnswers mischievouslyAbaw, storyahi ko na bi sang liguy mo sir?Kis-a e. mga barkada ko na classmate hagaray di magsulod kag bakasyon sa computeran. Sadja daw HahaGeneral Leads Giving encouragement to let him continue the topicReminiscing happilyTe sir, ano man nabatyag nyo after naman gali ya ka computersession nyo nag cutkamo classes?Sadya gid eh. Ako dan ang leader galling na konsensiya man ko magabot sabalay.Reflecting Directing thoughts and feelings back to himSomewhat guilty but stillradiates fromthe memory

Nurse-Patient Interaction (NPI)Day 5 11/28/2014NurseInteractionPatientInteractionNurse InferencePatientInferenceDaw kasubo sa aton sir aw?Bag o lang di halin bi mga bisita ko. Daw nasubo an man ta pag bye2x nila bha..Making Observations Verbalizing whatthe nurse perceivesOpenly respondsNahidlaw ka gid sa ila siguro?Oo.Consensual Validation Searching for mutual understandingFalls silenceNahidlaw ka gid sa ila sir aw?Kasadja kung ara sila pero mabatyagan ko naman nga kulang kung wala naman sila.Restating Repeating the main idea expressedResponds solemnlyStoryahe ko bi sir panu mo ma describe ang ka kulang na nabatyagan mo?Daw ka amo na e. kulang. Subo ka naman. Tapos na ang party.Exploring Delving furtherinto the subjectOpens upSo, na mean mo sir daw ka temporary lang ang kalipay nyu na mabatyagan. Maumpawan kamo if ara friend nyo pero gakadula man maglakat na sila?Siguro.. daw ka ako na lang dayun bi isa.Summarizing Organizing and summing up what have he had expressed.Reflects deeply

Assessment Tool Methodology

An adapted questionnaire the UCLA Loneliness Scale is used as a measure of loneliness. Its name derives from its having been developed at the University of California, Los Angeles (UCLA). It was first published in 1978 by Russell, D., Peplau, L.A., and Ferguson, M.L., and was revised in 1980 and 1996. The internal consistency of the scale was high and the reported correlations with measures of emotional loneliness, social loneliness, self-esteem, depression, and personality traits,supported the convergent and discriminant validity of the scale.

The scale consists of 20 items (11 positive and 9

negative), describing subjective feelings of loneliness, none of which refers specifically to loneliness. A 20-item scaledesigned to measure ones subjective feelings of loneliness as well as feelings of social isolation. Participants rate eachitem as either O (I often feel this way), S (I sometimes feel

this way), R (I rarely feel this way), N (I never feel this way). The 20 items are rated on a 4- point Likert scale in accordance with the rate of frequency, the following corresponding weights were assigned to every response. Scores on the scale range from 20 to 80 with higher scores reflecting greater loneliness.

Using data from prior studies of college students, nurses, teachers, and the elderly, analyses of the reliability, validity, and factor structure of this new version of the UCLA Loneliness Scale were conducted. Results indicated that the measure was highly reliable, both in terms of internal consistency (coefficient alpha ranging from .89 to .94) andtest-retest reliability over a 1-year period (r = .73).

Convergent validity for the scale was indicated by significant correlations with other measures of loneliness. Construct validity was supported by significant relations with measures of the adequacy of the individual's interpersonal relationships,and by correlations between loneliness and measures of health

and well-being. Confirmatory factor analyses indicated that a model incorporating a global bipolar loneliness factor along with two method factor reflecting direction of item wording provided a very good fit to the data across samples.

The nurse utilized this tool by allowing the patient to answer the questionnaire that best describes his responses. The response will be tallied, computed, analyzed and interpreted. The assessment tool was translated verbally according to patients dialect in order to understand the items asked and give accurate response.

Computation of Clients Score

The data treatment is at the ordinal level, where the MEAN score of the client per category was computed and ranked to determine the priority of the problem and the overall mean to indicate the level of patients loneliness as the basis of treatment to be applied throughout the entire Nurse Patient Relationship in utilization of Peplaus Theory.

Formula for Mean

The mean is obtained by dividing the summation of scores in all the questions in the assessment tool.

Table 1. Initial Assessment Score

Scale

Value(initial assessment phase)(final assessment phase)

Summation ofFrequency in eachScaleMEAN

UCLA ScoreSummation ofFrequency in each Scale BMEAN

UCLA Score1Never00

71

2Rarely00

3Sometimes110.553.55

4Always90.45

Total/ Overall AverageMean Score

20

1

800.89

UCLA Scoring:

21-30: People within this range would indicate manageable instances of loneliness and effective coping up.

31-40: People attaining this score-range are operating comfortably and experience an average level of loneliness.

41-60: People within this range struggle a little with social interactions, experiencing frequent loneliness.

61-80: Scores falling within this range would indicate a person experiencing severe loneliness.

Scale of MeansDescription

4 (61-80)Relatively Severe Tendency to Loneliness

3 (41-60)Relatively High Tendency to Loneliness

2 (21-40)Relatively Average Tendency to Loneliness

1 (1-20)Incompletely Answered Questionnaire

Interpretation of the Score Scale of Means Description

3.05 4.00Relatively Severe Tendency to Loneliness

2.05 - 3.00Relatively High Tendency to Loneliness

1.05 2.00Relatively Average Tendency to Loneliness

0.00 1.00Incompletely Answered Questionnaire

Relatively Average Tendency toLoneliness Relatively Severe Tendencyto Loneliness

Incompletely Answered Questionnaire Relatively High Tendency to Loneliness

1234

Figure 2. Evaluative ScaleUtilized

Figure 3. Evaluative Scale of MeanDuring Initial47Assessment

Relatively Severe Tendency to Loneliness

123455

Planning Phase

Table 2. Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES OF CARESubjective Data: v Nasubuan na ko di.. v Indi ko kisa mayo ka tulog gid. v Wala pa sila ka bisita sa akon bi. v Kadugay pa ko makapuli guru ni. Takan na ko di. v Subo e. La daan kalingawan gid. Objective Data v Lack of goaldirected behavior v Use of forms of coping that impede adaptive behavior (including inappropriate use of defense mechanisms, verbal manipulation) v Inability to meet role expectation (no exercise, poor concentration) v Behavioral changes: Impatience Frustration Irritability Discouragement

Ineffective Coping related to depression and feelings of hopelessnes s as evidenced by verbalizatio n of loneliness, decreased use of social support, poor concentrati on, impatience, irritability, insomnia, lack of energy, non participatio n at times, low self esteem and a score of 71 in UCLA which indicate a person experiencin g severe loneliness

Within 14 days of nursing intervention at NEGROS OCCIDENTAL DRUG REHABILITATION CENTER the patient will be able to: 1. Improve or increase collaboration with the rehabilitation nurse/staff.2. Assess coping abilities and skills. 3. Assist client to deal with current situation:a. Encourage communication with staff/S.O.b. Provide continuity of care with the same personnel taking careof the client as often as possible. c. Schedule activities so periods ofrest alternate with nursing care while increasing activities slowly.d. Assess client in use of diversion, recreation, relaxation techniques.e. Encourage client to try new coping behaviors while confront when behavior is inappropriate, pointing out difference between words and actions while providing external locus of control, enhancing safety.4. Provide meeting psychological needs.5. Promote wellness.a. Provide and encourage anatmosphere of realistic hope.b. Give information and sideeffectsof medications/treatments. c. Discuss ways to deal withidentified stressors.

Table 3. Monitoring Chart

Nursing Intervention/RationaleImplementation DaysEvaluation/Outcomes

1234567891011121314

Independent:

1. Visit Mr. PU in NEGROS OCCIDENTAL DRUG REHABILITATION CENTER. Discuss the purpose of the study and interview will be conducted. Establish rapport with Mr. Pu. [Establishing rapport will increase patient participation and ease in date gathering.]

2. Gather pertinent data about Mr. PU fromthe NODRC records and staff.[Baseline data will serve as the basis for comparison of any significant changes or alteration.]

3. Observe Mr. PUs self management towards his illness or towards the signs and symptoms of the disease (Bipolar). [Observation of his reaction towards illness will provide significant data and concrete confirmation of his lonelinessassessment.

After 14 days of continuousnursing intervention, effective illness management of the patient was attained as evidenced by:

1. Increase collaboration with healthcare providers.2. Participate in his planof care.3. Exhibit selfesteem and motivation.4. Continuous takes his medication while demonstrating improvement in rehabilitation.5. Alleviate sense of despair, social isolation and loneliness.

4. Determine Mr. PUshealth beliefs, patterns of coping with illness and attitude towards rehabilitation. [Determining Mr. PUs health belief pattern, self awareness, and perspective of his condition to have a concrete understanding of the subjective data gathered.]

5. Initiate NursePatient Interaction (NPI) with Mr. PU.[Provide care for clients in need of psychosocial intervention.]

6. Provide a safe environment for the client. [Physical safety of the client is a priority.]

7. Allow client to express opinions, perceptions, emotions in appropriate and safe manner while providing privacy if he desires and it is safe to do so. [Client may not feel comfortable in expressing feelings and may need encouragement

or privacy.

8. Encourage client to ventilate feelings in whatever way is comfortable verbal and nonverbal. Let the client know you will listen and accept what is being expressed. [Expressingfeelings may help relieve despair, hopelessness and so forth. Feelings are notinherently good or bad. You must remain nonjudgmental about the clients feelings and express this tothe client.]

9. Teach the client about problem solving process: explore possible options examine the consequences, of each alternative, select and implement an alternative, and evaluate the result.[The client may be aware of a systematic method for solving problems. Successful use of

problemsolvingprocess facilitates the clients confidence in the use of coping skills.]

10. Provide positive feedback at each step of the process. If the client is not satisfied with the chosen alternative, assist the client toselect another alternative. [Positive feedback at each step will give the client many opportunities for success. Encourage him to persist in problem solving, and enhance confidence. The client can also learn to survive making amistake.

Dependent NursingAction:

11. Monitor intake of daily medication (Olanzapine, Haloperidol, Valpros)[Assures adherence to medication. Observance of 10 rights of giving medication

should befollowed.]

Collaborative NursingAction:

12. Collaborate with the Rehabilitation nurse in the provision of daily medication. [Continuum of care.]

13. Review endorsement procedure and referral processes followed in NODRC14. Coordinate with the psychiatrist, Administrator, nurse and authorized persons regarding every interaction and results orprogress with theintervention taken on the client.

15. Assist in patients taking of assessment tools and follow up results to be utilized as a tool in determining nursepatient interaction and intervention.

Implementation Phase

The progress of Mr. PU on his coping up patterns were monitored and recorded for a period of14 days from November 24, 2014 to December 7, 2014. Reflected on the table below are the changes of his behavioral pattern while the nursing interventions were implemented throughout the 14day period.

NursingDiagnosisDay 1(November 24,2014)Day 2(November 25, 2014)Day 3(November 26,2014)Day 4(November27, 2014)Day 5(November 28,2014)

Ineffective Coping related to depression and feelings of hopelessness as evidenced by verbalization of loneliness, decreaseduse of social support, poor concentration, impatience, irritability, insomnia, lack of energy, non participation at times, low selfesteemand a score of45 in UCLA which indicate a person experiencing severe loneliness

Difficulty in socializing with others noted.Looks shyly and slightly withdrawn.Slightly hesitantto confide some informatio n.UCLA Loneliness Scale Questionna ire had been answered

Busy doing something but openly respond whenapproached. Quite hesitantbut willing to participate in discussion.

Remains calm but quite distant Somewhathesitant Slightlydrifting in thoughts

Patient takes the Duilford Zimmerma n Temperam ent Survey in the rehabilitati on. Quite reflective Shares abit ofremorse. Reminiscence.

Patient has been visited by friends.Respondssolemnly in deep reflectionUnattentiveExpressfeelings of loneliness and missing a cozyatmosphere.

Day 6(November 29, 2014)Day 7(November 30, 2014)Day 8(December 1, 2014)Day 9(December 2,2014)Day 10(December 3, 2014)

Present in the activity but does not participate. Low energy Quite distant and in deep thoughts Polite but stillprefers to be undisturbed. Privacy given.

Attended communion. Participative and listens intently on the homily.

Nurse and patient interaction conducted. Expressed feelings of despair and loneliness. Delved deeperinto cause of loneliness. Patient expressed missing past activities and hobbies. Patient reflectsroot of loneliness

Patient is ambivalent. Joined in the activity but lacks enthusiasm Patientconverse with other patients briefly.

Patient is hesitant at first in interacting with the activities.Patient isbeingwatchful withthemechanics of the game.Encourage totake part in the game and cheered onby both staffand fellowpatients.Patient expressed tiredness but in open expression.

Day 11(December 4, 2014)Day 12(December 5, 2014)Day 13(December 6, 2014)Day 14(December 7, 2014)

Patient is nostalgic after viewing favorite cartoons.Patient is being attentive in discussion about the cartoons.Possible coping up has been established especially in motivating the patient for planning to what course he will take for college.

Patient has played soccer after school. Patient eats dinner and quite tiresome, take his medicines, rest for a bit whilewatching his favorite show and finally get to sleep.

Patients relatives arrived. Patient interacted in the living room with the family.

Attended theHoly Mass. Patient interacted with some friends. Answered the UCLA Loneliness Scale again.

Table 4. Final Assessment Score

(final assessment phase)

Mean DifferenceSummation of Frequency ineach Scale BMEAN

UCLA Score

40.20

450.2090.45

0.4550.252.250.3020.10

0.35

20

1

800.56

1.30

Table 5. Mean Difference between the Initial and Final Assessment

Scale

Value(initial assessment phase)(final assessment phase)

MeanDifference

Summation ofFrequency in each ScaleMEAN

UCLA ScoreSummationof Frequency in each Scale BMEAN

UCLA Score

1Never00

7140.20

450.202Rarely00

90.45

0.453Sometimes110.553.5550.252.250.304Always90.45

20.10

0.35

Total/ Overall Average Mean Score

20

1

800.89

20

1

800.56

1.30

Figure 4. Comparative Level of Loneliness Tendency Between the Initial and Final AssessmentResult of Mr. PU

1234

1.30

Figure 5. Comparative Level of Initial and Final Assessment in Chart

1260.00%

1050.00%

840.00%

630.00%

420.00%

210.00%

0Sometimes AlwaysValueNeverRarely Sometimes Always

34Role1234 0.00%

CountPercent

Evaluation Phase

The clients mean difference was extracted by subtracting Mr. PUs initial assessment results of overall means from the initial assessment results. Overall mean of 1.30 was observed implying a significant improvement in clients tendency to loneliness.

Findings

The overall mean score Mr. PU in the initial assessment is3.55 that shows his relatively high tendency to loneliness. After 14 days of nurse-patient interaction and provision of nursing intervention, the clients overall mean score in the final assessment decreased to 2.25. The mean difference from the initial mean score is 1.30. This shows that there is improvement from the clients tendency to severe loneliness to be relatively tolerable while he keeps warding off from his loneliness tendency.

Conclusion:

Through the statistical findings presented, it can be concluded that by recognizing tendencies to loneliness of the client is an essential assessment tool to be utilized inPeplaus Nurse-Patient Interaction to further assist the patientin his needs and to understanding condition thatcan be the key to patients trust and further assistance to the restoration of self-integrity and promotion of health. The 14 day trial is just a short course and if the clients score keeps on improving in moderating his inclination towards loneliness, self-esteem, confidence, trust in others and successful rehabilitation would be inversely attain.

Recommendation:

The utilization of UCLA Loneliness Scale Assessment tool in resonance to Peplaus Interpersonal Relationship Theory as a concrete measurement in determining the loneliness and the gravity of emotional need and psychological support of the patient is highly recommended. It is essential not only to the psychologically challenged but also applicable to different kinds of patients with regards to emotional stability of a person.

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substance_use_headspace

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Letter to Conduct the Study

November 24, 2014

Dr. Ernesto A. PalancaNegros Occidental Drug Rehabilitation Foundation, Inc. Camp Gen Aniceto Lacson Compound,Victorias City, Negros Occidental

Dear Sir,

The undersigned, a post graduate student of Northern Negros State College of Science andTechnology, is currently undertaking a study of the patient with Bipolar Diagnosis.

In connection with the above statement, I would like to request a permission from your good office to allow me to conduct a study on one of your patient.

Your positive response on this matter is highly appreciated. More power and God bless!

Respectfully Yours,

TIFFANY ALTEZA C. UNTAL, RNMN STUDENT, NONESCOST

Noted:

Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.DCLINICAL PAPER ADVISER

Letter to Conduct the Study

November 24, 2014

MS. JUVY A. PEPELLONegros Occidental Drug Rehabilitation Foundation, Inc. Camp Gen Aniceto Lacson Compound,Victorias City, Negros Occidental

Dear Maam,

The undersigned, a post graduate student of Northern Negros State College of Science andTechnology, is currently undertaking a study of the patient with Bipolar Diagnosis.

In connection with the above statement, I would like to request a permission from your good office to allow me to conduct a study on one of your patient.

Your positive response on this matter is highly appreciated. More power and God bless!

Respectfully Yours,

TIFFANY ALTEZA C. UNTAL, RNMN STUDENT, NONESCOST

Noted:

Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.DCLINICAL PAPER ADVISER

Letter to the Patient

November 24, 2014

Mr. P.U.

Dear Sir,

The undersigned, a post graduate student of Northern Negros State College of Science andTechnology, is currently undertaking a study of the patient with Bipolar Diagnosis.

In connection with the above statement, I am humbly asking your permission to allow me to conduct a study your case.

Your positive response on this matter is highly appreciated. It would be a great privilege if you could shed light on this matter.

More power and God bless! Respectfully Yours,

TIFFANY ALTEZA C. UNTAL, RNMN STUDENT, NONESCOST

Noted:

Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.DCLINICAL PAPER ADVISER

Appendix B Assessment Tool

NEGROS OCCIDENTAL DRUG REHABILITATION CENTERManaged by:NEGROS OCCIDENTAL DRUG REHABILITATION FOUNDATION, INC.Camp Gen. AnicetoLacson Compound, Victorias City, Neg. Occ.

PSYCHOLOGICAL ASSESSMENT GUILFORDZIMMERMAN TEMPERAMENT SURVEY

I. PATIENT INFORMATION

Patient: P. U. Age: 16 y. o. Sex: M

II. TEST RESULTS

GRASEOFTPMRS2215171620109141613%5510201030515153510

AAVLABAVLABAVLABABABAVLA

III. TEST INTERPRETATION

Results show that the patient displays a highly impulsive behavior. He tends to act on the first thought that comes into his mind, without thinking about the possible consequences his actions might bring. As a result of this behavior, he has the tendency to get himself in trouble most of the time. It is also shown that his energy level is higher compared to most people of his age and sex. This would mean that he would enjoy doing activities at such a fast pace, as he does not get tired quickly. He may get things done as fast as possible. There might be times where he would get restless as well.In terms of sociability, the patient shows signs of introversion. He is most likely to stay in the background when attending social events. He seems to be socially withdrawn. He would usually isolate himself from crowds, as he prefers spending time alone. He does not seem to mind having only a few

friends with him. Apart from his introversion, he is also shown to be too submissive, meaning he is likely the one to follow rather than to lead. He is inclined to follow whatever he is being told to do, even if he feels that he cannot handle the responsibility given to him. It is also indicated that he has a hostile personality. Because of this, people might find it hard to get along with him. He tends to have an aggressive side which would come out when someone would provoke him. Also, he seems to be fond of belittling and mocking others. Whenever one commits a mistake, he is likely to make fun of that individual without being considerate of his/her feelings.Results also indicate that the patient may be suffering from a possible mood disorder. His feelings tend to shift from time to time, without any reason. He seems to be quite negative when it comes to himself. He may feel insecure most of the time, especially when being watched and criticized by others. He does not appear to take constructive criticisms lightly and would get affected easily. Also, he tends to be emotionally expressive. He has no difficulty with showing his feelings to others. Lastly, it is shown that he may have paranoia tendencies. He is usually suspicious of those around him, and he may find it hard to trust people easily.

Prepared by:Approved by: Daphne Elyse KengMs. Juvy Pepello

Junior Psychologist Administrator

Appendix B Assessment ToolUCLA LONELINESS SCALE

INSTRUCTIONS:

Indicate how often each of the statements below is descriptive of you.

4 indicates I often feel this way3 indicates I sometimes feel this way2 indicates I rarely feel this way1 indicates I never feel this way1. I am unhappy doing so many things alone4 3 2 1

2. I have nobody to talk to4 3 2 1

3. I cannot tolerate being so alone4 3 2 1

4. I lack companionship4 3 2 1

5. I feel as if nobody really understands me4 3 2 1

6. I find myself waiting for people to call or write4 3 2 1

7. There is no one I can turn to4 3 2 1

8. I am no longer close to anyone4 3 2 1

9. My interests and ideas are not shared by those around me4 3 2 1

10. I feel left out4 3 2 1

11. I feel completely alone4 3 2 1

12. I am unable to reach out and communicate with those around me4 3 2 1

13. My social relationships are superficial4 3 2 1

14. I feel starved for company4 3 2 1

15. No one really knows me well4 3 2 1

16. I feel isolated from others4 3 2 1

17. I am unhappy being so withdrawn4 3 2 1

18. It is difficult for me to make friends4 3 2 1

19. I feel shut out and excluded by others4 3 2 1

20. People are around me but not with me4 3 2 1

Scoring: Items 1, 5, 6, 9, 10, 15, 16, 19, 20 are all reverse scored. Keep scoring continuous.N C P | 6

Appendix C Nursing Care Plans NURSING CARE PLAN # 1

ASSESSMENTNURSINGDIAGNOSISRATIONALEDESIREDOUTCOMENURSINGINTERVENTIONJUSTIFICATIONEVALUATIONActual Cues

Subjective:

The patient verbalized,

Kis indi ko kabalo panu ihambal namean ko namaintindihan gid nila. Natayugan na sila kuno.

Wala ko ga upod kay ma OP (out of place) man lang ko toImpairedsocial interaction r/tSelf concept disturbance AEB Discomfort in social situations, receive a satisfying sense of socialengagement, family report of changes in interaction, dysfunctional interaction with others.

Definition:

Social isolation is the conditionof aloneness expe rienced bythe individual and perceived as imposed by others and as a negative or threatened state; impairedsocial interaction is an insufficient or excessive quantity orineffective quality ofsocial exchange.ShortTerm:1. Verbalize awareness of factors causing or promoting impaired social interactions

2. Identify feelings that lead to poor social interactions.

3. Express desire to be involved in achieving positive changes in social behaviors andIndependent:

A. Assess causative/contribu ting factors.

B. Assist patient/SO to recognize/make positive changes in impaired socialand interpersonal interactions.

a. This may result to conforming or rebellious pattern/ behavior whilenoting prevalent interaction pattern.

b. Once recognized, client can choose to change as he learns to listen and communicate in socially acceptable way.

After 14 days of NursePatient Interaction, theclient will be able to:

Verbalize feeling that lead topoor social interactionGOAL MET

Involve in social interaction.GOAL MET

Identify self positive reinforcement for the changes that are achieved.

japon sa tripnila. Objective:

v Discomfort in social situation

v Do not ask question

v Observed lackof attention during activitiesInsufficientor excessive quantity or ineffective quality of social exchange.

Source: Nurses Pocket Guide 10th Edition by Marilynn E. Doenges,Mary Frances Moorhouse, Alice C.Murr

interpersonalrelationships.

Long Term:

4. Give self positive reinforcement for changes that are achieved.

5. Develop social support system; use available resources appropriately.

C. Work with client to alleviate underlyingnegative selfconcepts

Collaborative:

D. Promote wellness by seekingcommunity programs for clientinvolvement that promote positive behaviors the clientis striving to achieve.

c. Negative self concept if left unresolved often impede positive social interactions. Attempts at trying to connect with another can become devastating to selfesteem and emotional well being.

D,There is adirect correlation between the musical portionof the brain and the language area, and the use of theseprograms mayresult in better communication skills.GOAL MET

Assess for environmental withdraw (time spent in room versus time spent with others).GOAL MET

NURSING CARE PLAN #2

ASSESSMENTNURSINGDIAGNOSISRATIONALEDESIREDOUTCOMENURSINGINTERVENTIONJUSTIFICATIONEVALUATIONActual Cues

Subjective:

The patient verbalized,

Nahuya na ko kis a kag na guilty sa napang himu ko,,

Wala ko pulos ya.. La na ko putoro.

Objective:

Emotionally stressed.

Facial grimace

Chronic Low SelfEsteemr/t Feelings of abandonment secondary to separation from significant other/s AEBLongstanding self negating verbalizations, Expressions of shame and guilt, Poor body presentation (eye contact, posture, movements)Nonassertive/passive

Definition:

Longstanding negative selfevaluation/ feelings about self or selfcapabilities.

Development of a negative perception of selfworth in response to a current situation.

Low self esteem disturbance describe as negative feelings about themselves, including the loss of confidence and self esteem, sense of failure to reach the desire, self criticism, reduced

Short Term:1. Accept support through the nurse patient relationship2. Identify areas of ineffective coping3. Examine the current efforts at coping4. Identify areas of strength5. Learn new coping skills

Long Term:

6. PracticeIndependent:A. Identify current stresses in PUs life including bipolar disorder

B. Assess current level of depression using UCLA Loneliness Scale.

a. When areas of concern are verbalized by the patient, he will be able to focus on one issue at a time.

b. If she identifies the mental disorder as a stressor, he will more likely be able to develop strategies to deal with it.

Determine if he is able to realistically identify problem areas.GOAL MET

Assess if he can identify any previous successes in her life.GOAL MET

Assess for environmental withdraw(time spent in room versus time spent with others).GOAL MET

Narrowedfocus

Feelings of helplessness, hopelessness, or powerlessness

Confusion about self, purpose, or direction of life

Source:Nurses Pocket Guide 10th Edition by Marilynn E. Doenges, MaryFrances Moorhouse, Alice C. Murrproductivity,which is directed destructive to others, feelings of inadequacy, irritable and being withdrawn socially.new copingskills.7. Focus on strengths

C. Involve PU in treatment and socialization activities. Stress importance of activity in helping recovery fromdepression and that he will have to make a consciouseffort to fightit.

D. Assist PU in discussing, selecting, and practicing positive coping skills (jogging, yoga, thought stopping

c. By focusing on past successes, he can identify strengths and buildon them in the future

d. Severely depressed individuals need assistance with decision making, grooming and hygiene, and nutrition Assess if thepatient follows through on learning new skillsand learned a lot about his medication and committed in complying with his medication regimen.GOAL METContinue to practice new coping skills as stressful situationsariseGOAL MET

Collaboration: E. Educateregarding the his medicine and medical regimen such as his therapy and session with the rehabilitation staff with its relationship to depression

F. Assist patient in coping with bipolar disorder, beginning with education about it.

e. By keeping individuals who are depressed active, social withdrawal is prevented.

f. Social activity helps the client deal with the depression. Patient should have a thorough knowledge of themedication and side effects

Nursing Care Plan #3

ASSESSMENTNURSING DIAGNOSISRATIONALEDESIRED OUTCOMENURSING INTERVENTIONJUSTIFICATIONEVALUATIONActual Cues

Subjective:

The patient verbalized,

Objective:

Decreased use of social supportDestructive behavior toward self or othersDifficulty asking for helpFatigueInability to meet basic

Ineffective Individual Copingr/t Altered mood (depression) caused by changes secondary to body chemistry (bipolar disorder)AEB Verbalization in inability to cope or ask for help Reported difficulty with life stressors Inability to problem solve Alteration in social participation Destructive

Ineffective individual coping may be manifestwhen a person verbalizes an inability to cope or to ask for help, is unable to meet basic needs or role expectations, cannot use problem solving techniques,has a high rate of illness or accidents, exhibits destructive behavior toward self or others

Short Term:2. Accept support through the nurse patient relationship2. Identify areas of ineffective coping3. Examine the current efforts at coping4. Identifyareas of strength5. Learn new coping skills

A. Identify currentstresses in PUs life including bipolardisorder

B. Assess current level of depression using UCLA Loneliness Scale.

d. When areas of concern are verbalized by the patient, he will be able to focus on one issue at a time.

e. If she identifies the mental disorder as a stressor, he will more likely be able to develop strategies to deal with it.

Determine if he is able to realistically identify problem areas.GOAL MET Assess if he can identify any previous successes in her life.GOAL MET Assess for environmental withdraw(time spent in room versus time spent with others).GOAL MET

needs androle expectationsStatements indicating inability to copebehavior towardself

Definition: Inability to form valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

Source:Nurses Pocket Guide 10th Edition by Marilynn E. Doenges, Mary Frances Moorhouse,Alice C. Murr(includingexcessive eating, drinking, or other illnesses related to emotional tension, is a chronic worrier, or exhibits chronic depression.

Long Term:

6. Practice new coping skills.7. Focus on strengths

C. Involve PU in treatment and socialization activities. Stress importance of activity in helping recovery fromdepression and that he will have to make a consciouseffort to fightit.

D. Assist PU in discussing, selecting, and practicing positive coping skills (jogging, yoga, thought stopping

f. By focusing on past successes, he can identi