INTRODUCTION

Dissociative Identity Disorder was previously known as multiple personality disorder. It is considered the moost serious of the dissociative disorders. Clients have two or more distinct personalities, each with its own behavior and attitudes. While there is no proven specific cause of DID, the prevailing psychological theory about how the condition develops is as a reaction to childhood trauma. Specifically, it is thought that one way that some individuals respond to being severely traumatized as a young child is to wall off, in other words to dissociate, those memories. When that reaction becomes extreme, DID may be the result. As with other mental disorders, having a family member with DID may indicate a potential vulnerability to developing the disorder but does not translate into the condition being literally hereditary. Dissociative identity disorder is characterized by the presence of two or more distinct or split identities or personality (different names, ages, tone of voices and appearance and dress) states that continually have power over the person's behavior. With dissociative identity disorder, there's also an inability to recall key personal information that is too far-reaching to be explained as mere forgetfulness, unremembered behaviours, discovery of items for which she cannot account, not recognizing oneself in front of the mirror Moreover, along with the dissociation and multiple or split personalities, people with dissociative disorders may experience depression, mood swings, suicidal tendencies, sleep disorders, anxiety, panic attacks and phobias, alcohol and drug abuse, compulsions and rituals, psychotic-like symptoms and eating disorders. Other symptoms of dissociative identity disorder may include headache, amnesia, time loss, trances, and "out of body experiences." Some people with dissociative disorders have a tendency toward self-persecution, self-sabotage, and even violence (both selfinflicted and outwardly directed). The primary treatment for multiple personality disorder is therapy, which may include hypnosis, grounding techniques, individual therapies such as art therapy, and/or talk therapy and cognitive-behavioral therapies. The goal is to get alters in communication with each other, so that the person does not continue to dissociate from reality. A secondary goal is to be sure the person is removed from any ongoing traumatic situations, such as removing a child from an abusive home. There is no particular drug or combination of drugs that is specific to the treatment of client with dissociative disorder. Pharmacologic interventions may be most useful in treating the target symptoms that often accompany dissociative identity disorder, as well as intrusive and hyper arousal symptoms. Depression is also a common presenting symptom of clients with dissociative disorder and may be what first brings them into the mental health system. No particular class of antidepressant is more effective than another; each needs to be evaluated on an individual basis. Anger and severe internal disequilibrium accompany dissociation in varying degrees. Antipsychotics can be a useful adjunct to treatment to assist the client in periods of dyscontrol or rapid dissociation. Atypical antipsychotics can be effective.

OBJECTIVES

NURSING HISTORY
DEMOGRAPHIC DATA Patient K.A.M is a 24 years old, female, a Filipino and Roman Catholic is currently residing at Taal, Bocaue, Bulacan. She was born on July 19, 1988 at Isabela, Leyte. CHIEF COMPLAINT Unremembered behaviour called by different names, being accused of the things unkown and the sense of going insane accompanied by suicidal ideations. HISTORY OF PRESENT ILLNESS 1 year PTA, client is exhibiting inability to recall key personal information that is too far-reaching to be explained as mere forgetfulness, unremembered behaviours, discovery of items for which she cannot account, not recognizing oneself in front of the mirror, sleep and eating disorders, depression, and the sense of being going insane. 4 months PTA, patient was encouraged to consult a psychiatrist with presenting signs and symptoms, exhibited auditory hallucinations and had severe anxiety attacks. The doctor initially diagnosed the patient of having paranoid schizophrenia s evidenced by the presenting clinical manifestations and thus refuses to continue the treatment compliance. 3 months PTA, client was referred to the Bulacan Psychiatric State Hospital for further evaluation. Initially, get baseline vital signs, mental status examination. 3 days PTA, through the therapeutic relationship and communication, therapies and different treatment modalities like hypnosis at home health care services done to the client she was finally diagnosed as having Dissociative Identity Disorder. Few hours PTA, client wishes to kill herself as someone inside her want to kill her or commit suicide so that a decision arises for client to be admitted at the hospital.

PAST MEDICAL HISTORY Patient had common cold and flu, experienced severe headaches, insomnia and amnesia, depression and anxiety and shizophrenia. She denies engagement on previous accidents but is always being warned because attacks commonly being manifested along the road. NUTRITIONAL-METABOLIC PATTERN Patient seldom eats her dinner because she feels tired from all day work at school and wishes instead to sleep in regaining energy. She spends longer time eating her breakfast and reports early satiety thus leaving half of the food on the plate not eaten. But there are times when returning home from school, she eats a lot, reporting that she feels hungry like a man not fed for a year. She stated that she was advised by her guardian to take vitamins for supplementation. She eats a piece of bread for breakfast and a cup of milk oftentimes and seldom eats rice ELIMINATION PATTERN Patient reports change in the frequency of bowel movements from the usual 2 times a day to 2-3 times a week. She describes it as bulky and takes an effort to be eliminated which made her decide to take oral laxatives. She voids at least 4 times per day draining amber to yellowish urine without any associated difficulties. SLEEP AND REST PATTERN Patient has difficulty falling sleep almost at all nights. She wakens at the middle of the night because of the current nightmares being experienced. It takes couple of hours to fall asleep again. Most of the time, she reads books in order for her to fall asleep and the usual drinking of warm water before bedtime but there are times drinking alcohol beverages soothes the discomfort of remaining asleep. Reports fatigue the day after and sometimes stated that she would be awaken lying on the floor and being confused how she got there. She wishes to sleep all-day during her leisure time.

COPING-STRESS PATTERN Patient believes appraising people is the most stressful situation in her life. She just recently loss her best friends trust and understanding, has had an argument with her tita and has had lost her interest in studying.

ROLES-ROLE RELATIONSHIP PATTERN Patient has a history of family abandonment due to a homicidal event. She is presently living with her tita who is not staying at home for longer periods of time arising from the need to work. She is a graduating Psychology student at a prestigious university in nearby their vicinities. She spends most of her time studying with her best friend. She has had recently a quarrel between her best friend. SENSORY- PERCEPTUAL PATTERN Patient needs to wear eyeglasses although out the day to appropriately perform daily tasks. Reports hearing buzzing of voices on her head and easily get startled when exposed to any environmental noises especially the sounds of a metal and developed fear on certain objects like a glass of coffee.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE
1ST DAY 2ND DAY Act out like a caring woman in the mid Act out like a young adult man adulthood Cooperative attitude and behavior Cooperative but has difficulty sitting still 3RD DAY Appears younger than age, acting out like a child Uncooperative and bizarre through exhibiting violent cues and acts towards others Uncomfortable if the nurse is too close Comfortable but is not Easily startling to environmental noises Wears clothing with long sleeves, eyeglasses, Wears pants and shirt, covered with black Wears kiddie apparel, tied on a ponytails, not appropriate to age but somehow jacket, not appropriate to weather and sex appropriate to weather but not to age appropriate to weather Relaxed, sudden shift from elation to sadness, Appears anxious or agitated and have Appears anxious and agitated and sometimes from calm to hyper alert and anxious difficulty sitting still violent often need to pace or move around a place Not recognizing self to mirror Not recognizing self to mirror Not recognizing self to mirror

MOOD AND AFFECT

1ST DAY Looks sad and lonely then shifts from being joyous and wears smile, uses sweet but low tone of voices Unable to identify any emotions or feelings 2ND DAY 3RD DAY Uses high tone of voices like that of an adult Looks terrified and may cry or scream or man attempt to hide or run away Bossy and act like a commander Report feeling dead inside Frightened or scared that someone wishes to kill him inside Irritated and anxious

THOUGHT PROCESSES AND CONTENT

1ST DAY 2ND DAY Knows the behavior, appearance and plans of Always theres a need to be obeyed, wishes to the other two alters hurt people when they do not do what she says 3RD DAY Experienced nightmares and flashbacks Reports hallucinations and buzzing voices in her head that someone wishes to kill her and ran before her

COGNITIVE/INTELLECTUAL FUNCTION
1ST DAY 2ND DAY Experienced memory gaps, period of time for Oriented to reality which she has no clear memories Losses concentration or paying attention when experiencing hallucinations and unable to communicate at all 3RD DAY Oriented to reality but unable to concentrate and has an impaired judgment, decision making and problem solving

SPEECH
1ST DAY Low tone of voice Coherent Calm and direct 2ND DAY Loud tone of voice Coherent Loud speech 3RD DAY Moderate to high tone of voice Rapid speech Incoherent as evidenced by the presence of loose association

PHYSICAL ASSESSMENT
AREA OF NORMAL FINDINGS EXAMINATION VITAL SIGNS T: 36.5-37.4C PR: 60-100 beats/min. RR: 12-20 breaths/min. BP: 120/80mmHg SKIN Varies from light to deep brown, ruddy pink to light pink No abrasions or lesions If pinched, skin goes back to previous state <3secs. Skin temperature is uniform at all areas Soft, moist in skin folds and axillae ACTUAL FINDINGS March 08, 2012 T: 36.4C PR: 61beats/min. RR: 19 breaths/min. BP: 100/60mmHg With lacerations at ventral forearms noted With bruises at forehead and ventral forearms With scar at right knee Pale Dry and irritated Light brown Pinched skin goes back 4 secs. Slightly cool to touch ACTUAL FINDINGS March 09, 2012 T: 37.5.C PR: 110 beats/min. RR: 25 breaths/min. BP: 140/90mmHg With lacerations at ventral forearms With bruises at forehead and ventral arm With scar at right knee Facial flushing Warm to touch diaphoretic Pinched skin goes back 3 secs. CLINICAL SIGNIFICANCE Vital signs are low during depressive state due to low amount of serotonin. Vital signs are increased when anxious because the body is compensating and the effect of norepinephrine takes place Lacerations and bruise are evidently due to self mutilating during depressive state or when the alter with homicidal rage pop out. Old scar indicates previous injury by either an accident or a physical abuse Facial flushing is due to increase in blood supply for compensation of the body related to anxiety. Diaphoresis is a compensatory mechanism when anxious. Slightly poor skin turgor and dry and irritated skin indicates fluid deficit and hygiene deficit related to depressive state present in an alter personalities.

NAILS

Pinkish in color Fingernails plate shape is in convex curvature Round, hard immobile Blanch test of the capillary refill has a

pale nailbeds Fingernails plate shape is in convex Round, hard immobile Slow capillary refills >2 secs.

Fingernails plate Pale nailbeds and slow capillary refill may shape is in convex indicate low blood concentration usually Round, hard when not having adequate resting periods. immobile capillary refills >3 secs.

HAIR

EYES

prompt return of pink, generally <3 secs. Evenly distributed on scalp Thick, silky and resilient No infestations or infections No scalp lesions Equal movement No discharge No discolocration Pinkish conjunctiva Sclera appears white No edemaoe tenderness on lacrimal glands Equal pupillary reaction to light

Thin strands No infestations/ infections No scalp lesions

Thin strands All of the findings are NORMAL. No infestations/ infections No scalp lesions

With dark circle around eyes noted Slight puffing of eyelids (+}eye Movement Eyes seem teary Sclera appears pale No tenderness on lacrimal glands Constricted pupils briskly reactive to light

(+}eye Movement Eyes seem teary Sclera appears white No tenderness on lacrimal glands Constricted pupils briskly reactive to light

Dark circle round eyes indicate not enough rest or sleep period related to the depressive state. Puffing of eyelids maybe present maybe in patient who has just recently being emotional and cried alot.

EARS

Color same as facial skin Symmetric position Presence of minimal cerumen Firm and no tenderness Pinna easily recoils

Color same as facial skin Symmetric in position Presence of minimal cerumen Firm and no tenderness Pinna easily recoils

Color same as facial The auditory examination were all to be skin found NORMAL. Symmetric in position Presence of minimal cerumen Firm and no tenderness

Pinna easily recoils

NOSE

Straight and symmetric No discharge No nasal flaring Uniform in color Facial sinuses are nontender Air moves freely to as the client breathes through the nares

MOUTH

NECK

Straight and symmetric No discharge Slightly congested No nasal flaring Uniform in color Facial sinuses are nontender Air moves slightly not freely to as the client breathes through the nares Lips are uniform in Lips are slightly dry color, soft, moist with symmetrical smooth contour Symmetric in contour Able to purse lips Able to purse lips Dry oral cavity 32 teeth, smooth enamel, pink gums with no retractions Muscles equal in size, equal neck symmetry head centered Superficial dilated Coordinated blood vessels noted movements No lesions or mass Lymph nodes are non-

Straight and symmetric No discharge With nasal flaring noted Uniform in color Facial sinuses are non-tender Air moves freely to as the client breathes through the nares Lips are slightly dry with symmetrical contour Able to purse lips Dry oral cavity

An increase need for oxygen can manifest nasal flaring

Maybe patient have low fluid intake or hygiene deficit NORMAL Maybe due to low fluid intake

equal neck The neck examinations were all found to be symmetry NORMAL. Superficial dilated blood vessels noted

palpable THORAX AND Symmetric LUNGS Spine is vertically aligned Antero-posterior to lateral diameter in ratio of 1:2 Full symmetric chest expansion No deformities and masses Resonate except over scapula Broncho and vesicular breath sounds ABDOMEN Unblemished skin, uniform in color Rounded or flat in contour Symmetrical Stools are brown to dark brown Color of emesis varies High-pitched irregular gurgles, 5-35 times/min. presently equal Dull in all four quadrants over bowel Non-tender Soft

Full symmetric chest expansion No deformities No masses Spinal column is straight and vertically aligned Normal breath sounds; medium pitch, medium intensity Resonate except over scapula Symmetrical Decreased sounds

Full symmetric chest expansion No deformities No masses Spinal column is straight and vertically aligned Rapid, breathing; medium pitch, medium intensity Resonate except over scapula

Rapid breathing is due to the effect of noreephinephrine during fight or flight response

Symmetrical Decreased bowel sound is maybe due to bowel Decreased bowel decreased gastric motility related to sounds depressive and anxiety episodes

No masses

THERAPEUTIC COMMUNICATION
NURSE PATIENT Good morning, ako nga pala si nurse Gretchen, ako ang magiging nurse mo simula ngayon at sa mga susunod na araw. Upang matulungan kita sa paggaling mo. TECHNIQUE USED ORIENTATION PHASE Offering self RATIONALE Builds trust and understanding Introduce self and identify relationship Withdrawn clients commonly fear close contact with someone Overcome nervousness and convey feelings of warmth, expertise and understanding to be more likely successful and to meet established goals Builds trust and self-esteem

Inaasahan ko na magiging maluwag sa puso mo na tulungan kita. Kung ditto sa lugar na to gusto mong makipagusap, sge. Mga 9 ng umaga hanggang 12 ng tanghali ang oras natin at depende sa haba narin ng mapaguusapan. May mga pagkakataon na pupunta rito kasama natin ang mahahalagang tao sa buhay mo.

ORIENTATION PHASE Nurse-client written contract Time, place, length of sessions When will be terminated Who will be involved in the treatment plan Cline responsibilities Nurse responsibilities ORIENTATION PHASE Utilization of Confidentiality

Ang anumang mapaguusapan natin ay makakaasa kang sa atin opo. Sige po. (Shy) lamang dalawa. May mga pagkakataong kailangan kong kausapin ang mga kaibigan mo at kapwa ko nurses pero makakaasa ka na hihingi muna ako ng permiso mula sayo. Ano nga pala ang gusto mong itawag ko sayo? ahmmm.. ako si angela.

WORKING PHASE

Provide

Broad Openings

opportunity for the client to introduce a topic Ideal in popping out thealters Concentrate on a single, important point Encourage continuation

Ilang taon na si angela?

Hmm. Di ko alam eh.

WORKING PHASE Focusing

ah. Tell me about angela..

Medyo mahiyain at ayoko WORKING PHASE talagang nakikisama sa mga tao.. General Leads ayoko ng ganitong nakikipagusap.. pasenya ka na ha.. (still in timid state)

sige. (nodding) nasusundan kita at ok lang yan..

Gaano ka ba naaapektuhan ng pagiging mahiyain mo?

ewanko, basta..tara na nga.. bakit ba kasi tayo nandito.. nagugutom na ko at masakit ang ulo ko kaya go na.. Parang nawawalan ka ng interes kausapin ako? Db sabi mo Masakit lang talaga ulo ko eh.. kanina gusto mo ng kausap? gusto ko pa matulog..

To be oriented more with the behviors unique to that specific alter WORKING PHASE Implicates that Accepting the nurse has heard and is willing to hear what the client wants to say WORKING PHASE Having the Encouraging client describe descriptions of her view of an perceptions experience. WORKING PHASE Verbalizing Making observations what the nurse sees in clients behaviour

Ayos lang ba ang pakiramdam mo?

Gusto ko lang matulog pa..

WORKING PHASE Focusing

sge. Naiintindihan ko kung yan ang gusto mo..

WORKING PHASE Accepting

In order for the conversation Concentrate on the feelings experienced by the client Implicates that the nurse has heard and is willing to hear what the client wants to say Boost the likelihood of the client to talk Giving the client to responsibility needed for her full recovery. Journaling helps client express feelings and thoughts through written form when otherwise has difficulty verbalizing due to the dissociation

Pagbalik natin, may assignment ka.. gusto ko isulat mo mamaya Oo sige.. ang mga naramdaman mo ngayong araw.. kung OK na ang pakiramdam mo mamaya. Asahan mong pupuntahan kita..maliwanag ba yun?

WORKING PHASE Summarizing Orientation Journaling

2nd day
Magandang Umaga eto nga pala si (smile lang.. unreal) nurse Kath.. Kami ang makaksama mo ngayong araw na to. ORIENTATION PHASE Offering self Collaborating with other staff Introduce again the self and relationship because client has amnesic episode Increases knowledge about the disorder and lessens own doubts and confusion and lessen clients fear about the validity of their disorder Praising client is essential in repeating same performance Encourage refreshment and continuation Direct client thought back to client A form of refreshment because client has commonly amnesic episode Recognizing the alter pop out that moment and know more about the personalities Giving realistic explanation of what the client perceives

Natutuwa ako at nakaayos ka ngayon Tara na.. sa garden. Ditto nalang bakit dun pa?

ORIENTATION PHASE Giving recognition WORKING PHASE Broad openings

ghela, diba sabi mo mas tahimik at ha? Eh mas tahimik nga ditto WORKING PHASE ligtas dun? ngayon. And I am Kristine..anong Reflecting ghela?

Sino si kristine?

I am Kristine. 14 years old. Period..

WORKING PHASE General leads WORKING PHASE Presenting reality

Pero hindi ka na bata.. you are already Ah basta.. and may date pa ko 24 years old.. and sabi mo nga may ngayon kaya bilis bilisan mo boyfriend ka di ba? lang..(masungit) nakakainip na dito eh. Parang ako lang mag isa.. Nararamdaman kong parang walang ha? Anong sinasabi mo? May nakakaintindi sayo.. boyfriend ako noh..medyo nag kaawaylang kami ngayon.. eh siya

WORKING PHASE Verbalizing the implied

Voicing what has been suggested or hinted at

kasi! boyfriend? oo! Baka tinatago niyo siya kaya wala pa siya till now? (galit) nagiging irritable kana? Hay naku, ilabas niyo siya.. totoo noh? gusto mong makatikim ha?? Kaya siguro kami nag aaway dahil sa inyo? (galit) Anong ibig sabihin mo sa makatikim? Obvious ba? Kaya ilabas niyo Gusto mo ba kaming saktan? na.amp! (aakma)

WORKING PHASE Focusing WORKING PHASE Making observation

Encourage clarification Concentrate on single, important point Verbalizing what the client has observed from the client

WORKING PHASE Restating

Teka lang! (medyo confront na..) ang stop for awhile) oo nga, (reflect) sabi mo kahapon sa akin, si angela maaruga, Tapos ngayon gusto mo kaming saktan?

WORKING PHASE Confronting Reflecting

Shows what is really meant by the clients statement and behaviour and anticipate if theres a need for an immediate action to prevent harm Direct clients thought back to the client Prevent harm outwardly done or injury

The primary personality is being called usually the protector in order to prevent so Gusto kong maramdaman ngayon ang protekyon na yan.. bilang iyong kaibigan.. tsaka may boyfriend nako.. (smile) smile a little) ok sge, pasensya na. Hinga ka muna ng malalim.. (tuturuan kung paano mag DBE) Anung nararamdaman mo ngayon? (shows rapid breathing) WORKING PHASE

Ok naman. (makalma)

gusto mu bang ipaliwanag ko ang Di na ok na.

WORKING PHASE Humor WORKING PHASE Grounding and techniques WORKING PHASE General leads WORKING PHASE

Alleviate clients anxiety Release tension relaxation Encourage continuation and aim at the established goal To help client what she has

nangyari sayo kanina? sge. Magpatuloy tayo. Tell us about you and your boyfriend? malungkot? May napagdaanan ka ba sa buhay na tulad ng nararamdaman mo ngayon?

Suggesting collaboration Masaya na malungkot.. (sad) WORKING PHASE Assessing relationship (stop.. cry flashback ng boses.. WORKING PHASE noises..) Encouraging comparison (Nurses empathize.. allow silence.. Silence offer hanky.. salamat. (parang confused pa) hmmm.. WORKING PHASE Broad opening madugo.. (stare lang) WORKING PHASE Broad opening Mga lalaki.. armado.. baril dito.. WORKING PHASE baril dun.. ang ingay.. maraeng Focusing sigaw.. (stare lang) (stop)

had experienced previously Further gather information about the clients experience Period of silence gives client time to express strong feelings and reflect towards self

Naiintindihan namin.. anong naiisip mo? Maari mo bang sabihin kung anong nangyari sa buhay mo? Anong ibig mong sabihin ng madugo sa buhay mo?

Encouraging client to verbalize further Encouraging client to verbalize further Concentrate on a single, most important detail

pagkatapos? Sge nakakasunod kami. Nakita ko sina mommy.. sina WORKING PHASE Sabihin mo ang nangyari.. daddy, sina ate.. sina kuya.. Accepting walang buhay.. (stare lang) (crying) comfort ni nurse Gretchen Napakaganid ng mundo! (medyo WORKING PHASE galit) Focusing ganid? basta. WORKING PHASE Focusing Alam kong kahit papaano nagging reflect) WORKING PHASE mabuti kang kaibigan at girlfriend.. sa basta. Wag kang makulit..ayoko na Cognitive reframing mga taong mahalaga sa iyo. At huwag alalahanin pa. Ibaon na. Reflecting mong isipin na you deserve to witnessed that kind of tragedy. And ypu deserve to lose them.

Shows active listening and willingness

To further elaborate Seek clarifications Helping the client that the experienced is not deserved by her and is not to put the blame on Avoid negative self talk that will complicate more the

kalimutan?

Naiinis na ko sayo.. will u just shut WORKING PHASE up! (galit ulit) Translating into feelings kayo may kasalanan eh.. sa mga ganyan niyo.. kayongl ahat!! Maaari ka bang kumalma muna? Oo na! WORKING PHASE Confronting Ang sabi mo parang nalulungkot ka Bahala na.. WORKING PHASE kasi nawala na ang lahat? Formulating plan of action Anong gagawin mo sa mga taong natitira pa sayo? Sa higit kalahating oras na nag usap Naku wala. Aarte lang yun..asan TERMINATING PHASE tayo.. makakaasa ka na sa atin lamang nga ba sila? Summarizing tatlo ang mga ito.. N2: may gusto ka bang ipaalam sa mga kaibigan mo? sge. Hanggang sa muli. Paalam. Sge. TERMINATING PHASE

dissociative episodes Encourage continuation and seeking clarifications

Approach client in nonjudgmental way Help the client in enhancing coping strategies, decision making and problem solving Recall client of the important points being conversed to decrease ignorance and participate well the next time

End the conversation

NURSING CARE PLANS

ASSESSMENT PLANNING S: Dapat noon ko pa Short term goal ginawa to eh, para hindi na ko nasaktan, para hindi Partially compensatory na ko nagkaganito. After 5 hours of nursing O: intervention, the patient >with lacerations and will manage anger towards bruises on the ventral self and others. forearms >with dark circle round eyes noted >sudden mood swings >clenched fists INTERVENTION Focus on examining the clients behaviors closely for abrupt changes that may signal a risk for suicide. (gestures, threats and plans). RATIONALE EVALUATION Close observation allows Patient nurse to intervene early in PREVENTED. and interrupt selfdestructive act: also provides opportunity to interact with the client rather than resorting to physical interventions. Safety is the number one priority. Behavioural changes that are clues to risk for violence are important for staff to anticipate ensuring the clients safety. condition

Facilitate on monitoring behavioral changes such as: -voice tone -facial expressions -movements -verbal expressions Restrict from passing judgment on the client, instead let the client know she is a worthwhile individual with strengths and not responsible for early childhood traumas.

NURSING DIAGNOSIS RISK FOR SUICIDE and OTHER-DIRECTED VIOLENCE related to the presence of auditory hallucinations and an alter who wishes to kill self (Kristine) secondary to

The client is relieved from blame, which decreases guilt and shame and builds self-esteem.

Facilitate on structuring Calm surroundings the environment to reduce precipitate less stressful external stimulation. internal state within the

dissociation.

-reduce noise, lights and client and reduce the risk extraneous activities for violence. -assist the client to avoid stressful environment when practical. Facilitate on assisting the client to identify alternatives to aggression or violence. -verbalize feelings in a safe setting -write thoughts and feelings in a journal Depend on administering medication: -Olanzapine(Zyprexa) 10mg/mL IM PRN These activities will divert the overwhelming impulses of anger and hostility toward constructive behviors.

May mediate antipsychotics activity by both dopamine and serotonin type 2 ( 5hydroxytryptamine [HT]2) antagonism: also mat antagonize muscarinic receptors, histaminic (H1)and alpha adrenergic receptors

ASSESSMENT S: Nandiyan na sila... hinahabol nila ko... nandiyan na sila! as verbalized by the client. O: >poor eye contact >hypervigilant, scanning >Scared >diaphoretic >Facial flushing >BP:150/90 PR: 110bpm RR: 25rpm

PLANNING Short- term goal Partially compensatory After 4 hours of nursing interventions, the patient appears relaxed and verbalizes healthy ways to deal with them.

INTERVENTION Facilitate on assessing palpitations, elevated pulse and blood pressure.

RATIONALE Changes in vital signs may suggest the degree of anxiety the client is experiencing Feelings are real, and it is helpful to bring them out in the open so they can be discussed and dealt with

EVALUATION Patients IMPROVED.

condition

Facilitate on acknowledging fear/anxiety by validating observations with client. (You seem to be afraid?) Facilitate on acknowledging reality of situation as the client sees it, without challenging the belief. Facilitate on maintaining frequent contact with the client. Be available for listening and talking as needed.

Client my need to deny reality until ready to deal it. It is not helpful to force the client to face facts.

NURSING DIAGNOSIS SEVERE ANXIETY related to acute stressor secondary to the presence of auditory hallucinations.

Establishes rapport, promotes expression of feelings and helps client look at realities without confronting issues they re not ready to deal with. False reassurance maybe interpreted s lack of understanding or honesty, further isolating the client.

Restrict from empty reassurances, with statements of everything will be alright. Instead, specific information.

Facilitate on instructing relaxation techniques such as deep-breathing exercises.

Mindfulness is a method of being in the here and now, concentrating on what is happening in the moment. Requires the nurse the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal Depresses the CNS at the limbic system and subcortical level of the brain.

Facilitate on providing therapeutic use of self and touch.

Depend on administering medication: Diazepam (Valium) 5mg IM PRN

ASSESSMENT S: I have to strive harder at all times... Im trying to do everything to please him but it was all nonsense... wasted! as verbalized by the client. O: >restless >negative observed >angry

PLANNING Long term goal Partially compensatory After a month of nursing interventions, patient will enhance coping strategies and its positive effects on life functions

INTERVENTION Facilitate on protective the client from harm injury during dissociate episode: accompanied client to assigned area, move furniture against the light prevent others to injury cause by client confused state. Facilitate to demonstrate to the client that staff will intervene to help the client cope more effectively during times of dissociation: -remain calm and accepting of the clients behaviour -listen actively to the client and try to identify which personality is currently dominant -arrange protection if violent personality dominates. -direct primary personality to monitor and control the behaviours of the

RATIONALE EVALUATION Client my become Patients confused, disoriented, or IMPROVED frightened during dissociative episodes and may require safety measures by an alert staff.

condition

self-talks

as A reliable confident staff, using a consistent team approach, helps to assure the client that someone in control when the client is unable to cope and may fear going insane or falling apart.

NURSING DIAGNOSIS INEFFECTIVE INDIVIDUAL COPING related to a need from escape from dissociation.

potentially violent personality can be called on to prevent violence. Facilitate to structure the environment to reduce stimulation, such as: -loud noises, -bright lights, -or extraneous movement. Facilitate to assist the client to use new alternative coping methods: -provide opportunities for the client to vent anger, fears, frustration, shame or doubt in trusted environment. -engage the client in physical activities that require energy and concentration -encourage the client to write thoughts, feelings, and fears in a diary or log. A less stressful external environment generally helps to calm the clients internal state and prevents or minimizes dissociate symptoms. The client is encouraged to deal with painful feelings, thoughts, and conflicts in a healthy, effective manner rather than using maladaptive denial.

Facilitate to praise the Praise client for using effective repetition coping strategies. behviors.

reinforces of adaptive

DRUG STUDY
GENERIC BRAND CLASSIFICATION DOSAGE AND ROUTE MECHANISM OF ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING IMPLICATIONS

FLUOXETINE Prozac HYDROCHLORIDE

Atypical antidepressant (selectiveserotonin reuptake inhibitor)

20 mg/cap OD PO

Inhibits the CNS neuronal uptake of serotonin

Short-term Hypersensitivity to management drugs of depressive illness Taking with Monoamine oxidase (MAO) inhibitors within 14 days of starting therapy

Nervousness Anxiety Insomnia Headache Drowsiness Tremor Dizziness

-Observe 10 Rs of administering medication -Use cautiously in patients at high risk for suicide or a history of hepatic, renal, cardiovascular disease, DM or seizures. -Should avoid giving in the afternoon to prevent sleep disturbances. -Rashes or pruritus may appear usually early in the treatment.

GENERIC

BRAND

CLASSIFICATION

DIAZEPAM

Valium

DOSAGE AND ROUTE Anxiolytics 5mg/ml (Benzodiazepine) IM PRN

MECHANISM INDICATION OF ACTION Depresses the CNS at the limbic system and subcortical level of the brain. Tension, muscle spasm, moderatesevere anxiety

CONTRAINDICATION SIDE EFFECTS Known hypersensitivity to drug Drowsiness Lethargy Transient hypotension Bradycardia Hangover Blurred vision

NURSING IMPLICATIONS Observe 10 Rs of administering medication Do not use with alcohol and any CNS depressant Watch out for signs of withdrawal syndrome

GENERIC

BRAND

CLASSIFICAT ION

DOSAGE AND ROUTE

MECHANISM ACTION

OF

INDICATION

CONTRAINDICATIO N

SIDE EFFECTS

NURSING IMPLICATIONS

OLANZAPINE

Zyprexa

Atypical antipsycho tics

10mg Unknown; may per mL mediate IM PRN antipsychotics activity by both dopamine and serotonin type 2 (5hydroxytryptamin e [HT]2) antagonism: also mat antagonize muscarinic receptors, histaminic (H1)and alpha adrenergic receptors.

Acute and Known maintenance hypersensitivity treatment of to the drug. schizophrenia and other psychoses drug where positive symptoms (e.g., delusions, hallucinations , disordered thinking, hostility, and suspiciousnes s) and/or negative symptoms (e.g., flattened affect, emotional and social withdrawal, poverty of speech) are prominent.

Headache, dizziness, somnolence, agitation, postural hypotension , intramuscula r site injection discomfort, hypotension , bradycardia with or without hypotension or syncope, tachycardia.

Observe 10 Rs of administering medication. Assess mental status, orientation, mood, behaviour, presence of hallucinations and type before initial administration and every month. Assess dizziness, faintness, palpitations, tachycardia on rising. Assess for neuroleptic malignant syndrome: hyperpyrexia, muscle rigidity, increased CPK, altered mental status, for acute dystonia (check chewing, swallowing, eyes,

pin rolling). Extra pyramidal effects (EPS) including akathisia, tardive dyskinesia, pseudoparkinsonis m. Provide decreased stimuli by dimming light, avoiding loud noises. Provide supervised ambulation until stabilized on medication; do not involve in strenuous exercise program because fainting is possible; patients should not stand still for long periods. Inform patient that orthostatic hypotension occurs often and to rise from sitting or lying position gradually. Do not withdraw this drug abruptly, or EPS may result: drug should be withdrawn slowly.