I.

OBJECTIVES
GENERAL:
This case study of our group aims to come up with in-depth understanding of Alcohol- Induced
Psychosis and for all student nurses to be able to give appropriate nursing management and for all the
aspect that contribute to and affect the condition patient of the said disorder.

SPECIFIC OBJECTIVES
KNOWLEDGE:
 To determine the signs and symptoms on the current history and other manifestation of the patient
 To be able to know the psychopathology of Alcohol- Induced Psychosis based on the patient’s
history
 To be acquitted with the different drugs ordered
 To know the Anatomy and Physiology of the organ/system involved
 To be able to use the nursing process as the structure of care of the patient

SKILLS:
 To identify normal vs. abnormal assessment data
 To promote safety, comfort and privacy of client
 To enhance skills in managing and caring for clients with the said disorder

ATTITUDE:
 To institute therapeutic and empathetic relationship between student nurse and patient

 To apply and use the different therapeutic communication techniques in interacting with the
patient
 To be more patient in dealing with the client
 II. INTRODUCTION
Alcohol is a neurotoxin that damages the brain in a complex manner through prolonged exposure
and repeated withdrawal, resulting in significant morbidity and mortality. Alcohol-related
psychosis is often an indication of chronic alcoholism; thus, it is associated with medical,
neurological, and psychosocial complications. It is a secondary psychosis that manifests as
prominent hallucinations and delusions occurring in a variety of alcohol-related conditions. For
patients with alcohol use disorder, previously known as alcohol abuse and alcohol dependence,
psychosis can occur during phases of acute intoxication or withdrawal, with or without delirium
tremens. In addition, alcohol hallucinosis and alcoholic paranoia are 2 uncommon alcohol-
induced psychotic disorders, which are seen only in chronic alcoholics who have years of severe
and heavy drinking. Lastly, psychosis can also occur during alcohol intoxication, also known as
pathologic intoxication, an uncommon condition the diagnosis of which is considered
controversial.

The definitions for the different levels of drinking include the following:

 Moderate Drinking—According to the Dietary Guidelines for Americans, moderate

drinking is up to 1 drink per day for women and up to 2 drinks per day for men.
 Binge Drinking—SAMHSA defines binge drinking as drinking 5 or more alcoholic
drinks on the same occasion on at least 1 day in the past 30 days. The National Institute
on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as a pattern of
drinking that produces blood alcohol concentrations (BAC) of greater than 0.08 g/dL.
This usually occurs after 4 drinks for women and 5 drinks for men over a 2 hour period.
 Heavy Drinking—SAMHSA defines heavy drinking as drinking 5 or more drinks on the
same occasion on each of 5 or more days in the past 30 days.

RISK FACTORS
 Chronic Alcoholism: a pathological condition resulting from the habitual use of alcohol
in excessive amounts
 Thiamine deficiency
 Alcohol-dependent withdrawal
 Comorbid substance abuse: use of other addictive substances e.g. Cocaine,
amphetamines, marijuana, etc.
 Lack of psychosocial support
 Comorbid psychotic & mood diorders e.g. Obsessive-Compulsive Disorder, Bipolar
affective disorder, schizophrenia, etc.
 Psychological factors: inconsistency in the parents behavior, stress, poor role modeling,
lack of nurturing
 Socio-environmental factors: Cultural factors, peer behaviors, society, availability of
substances
 Gender: More common in men

HOW ALCOHOLIC PSYCHOSIS OCCURS IN THE BRAIN

As alcohol enters the brain, it alters proteins involved in the regulation of neurotransmitters and
their pathways. Among these different brain pathways, the paths of dopamine and serotonin
make up the dopaminergic system, the system most affected by alcohol.  The overstimulation of
the dopaminergic system causes rapid-firing of the brain’s neurons, causing a flood of
stimulation. Similar to the brain functioning of those with schizophrenia or suffering a psychotic
episode, the flood of stimulation causes the person to hear, see, or sometimes smell, things
around them that are not present; this is called a hallucination.

THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

DISORDERS (DSM-5)

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines a careful criteria to
distinguish alcohol psychosis from other types of psychoses, including schizophrenia and illicit
substance-induced psychotic episodes.

To be diagnosed with an (Alcohol Use Disorder) AUD, individuals must meet certain diagnostic
criteria. Some of these criteria include problems controlling intake of alcohol, continued use of
alcohol despite problems resulting from drinking, development of a tolerance, drinking that
leads to risky situations, or the development of withdrawal symptoms. The severity of an AUD—
mild (2-3 criteria), moderate(4-5 criteria), or severe (6 or more criteria) —is based on the
number of criteria met. (DSM 5)

The new DSM describes a problematic pattern of use of an intoxicating substance leading to
clinically significant impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period:

1. The substance is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful effort to cut down or control use of the
substance.
3. A great deal of time is spent in activities necessary to obtain the substance, use the
substance, or recover from its effects.
4. Craving, or a strong desire or urge to use the substance.
5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at
work, school, or home.
6. Continued use of the substance despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreational activities are given up or reduced because
of use of the substance.
8. Recurrent use of the substance in situations in which it is physically hazardous.
9. Use of the substance is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance.
10. Tolerance, as defined by either of the following:

 A need for markedly increased amounts of the substance to achieve intoxication

or desired effect.
 A markedly diminished effect with continued use of the same amount of the
substance.
 11. Withdrawal, as manifested by either of the following:

 The characteristic withdrawal syndrome for that substance (as specified in the
DSM- 5 for each substance).
 The substance (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms.

SIGNS AND SYMPTOMS

Substance Abuse

1. Denial 2. Poor judgment

3. Minimizes use of substance 4. Limited insight
5. Rationalization 6. Low self-esteem
7. Blaming others for problems 8. Ineffective coping strategies
9. Anxiety 10. Difficulty expressing genuine feelings
11. Irritability 12. Impaired role performances
13. Impulsivity 14. Strained interpersonal relationships
15. Feelings of guilt, sadness, anger and 16. Physical problems e.g. sleep
resentment disturbances and nutritional deficits

Psychosis

Early stage psychosis:

 difficulty concentrating
 depressed mood
 sleep changes—sleeping too much or not enough
 anxiety
 suspiciousness
 withdrawal from family and friends
 ongoing unusual thoughts and beliefs

Later stage psychosis

 delusions
 hallucinations
 disorganized speech—switching topics erratically
 depression
 anxiety
 suicidal thoughts or actions
 difficulty functioning

DIFFERENTIAL DIAGNOSIS
Signs and symptoms of alcoholic psychosis can be confused with the psychosis caused by other
illicit drugs, such as cocaine and amphetamine.

Types of Substance Signs and Symptoms

Abuse
Intoxication Withdrawal
1. Alcohol Slurred speech, unsteady gait, lack Hand tremors, sweating, elevated
of coordination, impaired attention, PR and BP, insomnia, anxiety,
concentration, memory, and nausea and vomiting, transient
judgment, inappropriate sexual hallucination, seizures
behavior, vomiting,
unconsciousness, resp. depression,
hypotension
2. Amphetamines Euphoria, hyperactivity. Hyper- Dysphoria, fatigue, unpleasant
vigilance, talkativeness, anxiety, dreams, insomnia, increased
grandiose, hallucinations appetite, depressive symptoms,
tachycardia, elevated BP, dilated paranoid ideation, hallucinations
pupils, perspiration and chills, ,increased sexual activity
chest pain, confusion, cardiac
dysrhythmias
3. Sedative, hypnotics, Slurred speech, lack of Increased PR, RR, BP and Temp,
anxiolytics coordination, unsteady gait, labile hand tremors, insomnia, anxiety,
mood, impaired attention, stupor nausea, psychomotor agitation
4. Opoids Apathy, lethargy, psychomotor Anxiety, yawning, nausea and
retardation, impaired judgment, vomiting, dysphoria, sweating,
agitation insomnia
5. Hallucinogens Sweating, tachycardia, fear of Flashbacks and perceptual
losing one’s mind, impulsivity disturbances
6. Inhalants Dizziness, nystagmus, lack of No withdrawal symptoms
coordination, slurred speech,
unsteady gait, tremor, muscle
weakness, blurred vision

Psychosis should be suspected when symptom severity exceeds those anticipated during acute
alcoholic intoxication.  Clinical assessment is necessary to make a distinction between
substance-induced brain disorders and mental illness. Alcohol psychosis has a high degree of
disorientation, misjudgment and depression problems, similar to symptoms seen in those with
schizophrenia. Contrary to schizophrenia, however, the alcohol induced symptoms cease after a
few weeks of abstinence and imposes less functional impairment.

Alcohol idiosyncratic intoxication is an unusual condition that occurs when a small amount of
alcohol produces intoxication that results in aggression, impaired consciousness, prolonged
sleep, transient hallucinations, illusions, and delusions. These episodes occur rapidly, can last
from only a few minutes to hours, and are followed by amnesia. Alcohol idiosyncratic
intoxication often occurs in elderly persons and those with impaired impulse control.

DIAGNOSTIC PROCEDURES AND TEST

Laboratory evaluation should include the following:
 Complete blood cell count to rule out blood dyscrasias, infection, and anemia
 Basic metabolic panels
 Liver function test: Elevated ratio of alanine aminotransferase (ALT) to aspartate
aminotransferase (AST) suggestive of alcohol abuse; elevated ALT and AST-liver failure
due to multiple causes; elevated GGT compared with elevated liver enzymes has higher
specificity for alcohol dependency
 Urinalysis to determine the presence of a urinary tract infection and determine renal
function
 Stat urine or serum drug screen to determine if illicit drugs are contributing to psychosis
and change in mental status
 Stat urine or serum toxicology screen for levels of acetaminophen, tricyclic
antidepressants, aspirin, and other potential toxins from either an accidental or deliberate
overdose
 Prothrombin time
 Stool for occult blood
 BAL measurement (although a patient may appear intoxicated, clinical intoxication can
be determined only by BAL)
 Thyroid-stimulating hormone (TSH)
 Vitamin B-12/folate
 Rapid plasma reagin (RPR)

Imaging Studies:

 If a head injury is suspected, a CT scan is recommended to rule out a subdural hematoma.

 In those with comorbid schizophrenia and alcoholism, MRIs have shown that the gray
matter volume deficits in the prefrontal and anterior superior temporal regions is greater
than in those with schizophrenia and alcoholism alone.
 Chest radiography can be considered for all homeless patients, elderly patients, and
patients with risk factors for tuberculosis.

COMPLICATIONS

 Wernicke-Korsakoff syndrome: a neurological disease characterized by the clinical

triad of confusion, the inability to coordinate voluntary movement (ataxia), and eye
(ocular) abnormalities

 Korsakoff psychosis (or Korsakoff amnesic- or amnesic-confabulatory state): a mental

disorder characterized by disproportionate memory loss in relation to other mental
aspects

 Cardiac Myopathy: chronic disease of the heart muscle

 Cirrhosis: a slowly progressing disease in which healthy liver tissue is replaced with
scar tissue, eventually preventing the liver from functioning properly

 Leukopenia: a reduction in the number of white cells in the blood, typical of various
diseases
  Thrombocytopenia: a reduction in the number of platelets in the blood causing bleeding

TREATMENT AND MANAGEMENT

The first and most important treatment for alcohol-induced psychosis is the cessation of alcohol;
however, for chronic, heavy drinkers, withdrawal may require medical intervention.  Alcoholic
psychosis symptoms are usually self-limiting; the symptoms of psychosis should end after the
effects of alcohol have dissipated. No drug is usually required for the treatment of alcohol-
induced symptoms. Only in extreme cases, individuals may require the support of anti-psychotic
drugs.

Chronic thiamine deficiency is a causal factor that can influence the development of alcohol
psychosis during withdrawal. Typically, chronic heavy drinkers do not have balanced and
healthy diets, which over time, leads to nutritional deficits. Treatment involves nutritional
replenishment, including folic acid and thiamine supplements. Benzodiazepines may also be
used, by medical professionals in a detox setting, to ease withdrawal symptoms. For severe
psychosis, antipsychotics like haloperidol may also be administered. Proper dietary care,
cautious use of medications and moral support are the keys to helping individuals through an
alcoholic psychosis.

EPIDEMIOLOGY

 Filipinos are the 2nd highest alcohol consumers in Southeast Asia

 In as much as 50% of Japanese, Chinese, and Korean populations, the likelihood of
alcohol-related disorders occurring is less because of the absence of aldehyde
dehydrogenase.
 III. PATIENT’S PROFILE

NAME: TM
ADDRESS: Ipil, Echague, Isabela
GENDER: Male
AGE: 51 years old
BIRTHDAY: June 26, 1964
PLACE OF BIRTH: Echague, Isabela
NATIONALITY: Filipino
MARITAL STATUS: Married
RELIGIOUS PREFERENCE: Roman Catholic
ATTENDING-PHYSICIAN: Dr. J. S.
ADMISSION DATE AND TIME: November 7, 2015 (10:55am)
ADMITTING DIAGNOSIS: Alcohol- Induced Psychosis
SOURCE OF INFORMATION: TM, chart
DATE HANDLED: December 8-9 and 15-16, 2015
 IV. NURSING HEALTH HISTORY

Past Health History

The client stated that he is not a sickly person. Among the diseases he already
experienced are mumps, chicken pox, common colds and cough. He usually uses OTC drugs
such as antibiotics and paracetamol to manage them. He mentioned that he cannot remember if
he received any vaccination during his childhood. Furthermore, he doesn’t have any allergies on
any food or medications.

Family Health History

(+) Alcohol- induced psychosis (+) Hypertension
(-) Asthma (-) Diabetes Mellitus
(-) COPD
(-) Cancer
(-) Tuberculosis

Present Health History

3 weeks PTA, the client had a big misunderstanding with his elderly sister pertaining to
ownership of their farm land. As coping mechanism with stress, he started to drink alcohol more
frequently than the usual, consuming upto 9 bottles of Redhorse daily for a week. Concurrently,
the client got so depressed with the situation and decided to confine himself in his bedroom with
minimal amount of water and food (1 skyflakes and 1 bottle of water) to sustain him. Alone in
his room, he spent and wasted his time just reading the bible and playing the guitar while
ignoring his family members and other important stuff outside the doors. For the past few days
of self-confinement, he remembers having hand tremors, headache and general malaise. Later on,
he experienced irritating auditory hallucinations and described it to be fighting animals (Cats,
pigs, bats) coming from the ceiling. Therefore on April 12, 2015 he decided to take their ceiling
down to stop the noise but he found out that there was nothing in there. His family members got
frightened and worried on what is happening to Client TM thus prompting them to ask for some
help in a nearby hospital. They advised them to consult at CVMC- Psychiatric ward for further
management. Finally, he was brought via ambulance and got admitted at the CVMC- Psychiatric
ward on April 13, 2015 with the admitting diagnosis of Alcohol- induced psychosis.
Personal Health History
According to the client, he is not a cigarette smoker. He drinks alcohol (red horse,
“bilog”) at least thrice a week consuming 3 bottles each day. He is fond of attending barangay
events and occasions like barrio fiestas.
 V. PSYCHOSOCIAL ASSESSMENT COMPONENTS

Background:
Client TM is a 51 y/o male, currently residing in Ipil,Echague, Isabela. He is married and
blessed with 3 children. His native tongue is Ilocano but can also speak tagalog and English well.
As a Roman Catholic, he believes that Jesus is his protector. “Lagi akong nagbabasa ng Bibliya
ma’am, I want to become a priest”, he also verbalized. Among the Bible verses, he quoted “Love
one another” as his favorite one.
According to him, he started to drink alcoholic drinks such as San Miguel Gin “Bilog”
when he was still in High school. “Broken family kam ngamin, babaero ken manginum ni tatang
ku ta duwa ti cabaret mi idi ma’am,” he explained. He also added that since then, every time he
gets stressed out because of problems at home or at school, he drinks alcohol with his friends to
relax and enjoy himself.

General assessment and motor behavior:

The client is 5’8’’in height and has ectomorphic body type. On the interaction, he wore
ripped shorts, noticeably wore no underwear and has a slight body odor. He has a keloid on his
left wrist which he got from a fight with his brother years ago. “ Matagal na ito maam, tinabas
ako ng kapatid ko nung naglasing kame,” he explained. He also has a burn mark about 2 inches
below his left nipple which he got during their Bonfire (camping) back in highschool.
He is cooperative and submissive to the activities conducted to him. He is friendly and
likes to tell jokes during the interaction. He was able to maintain body position comfortably and
can make some eye contact. His gait while walking is steady and balanced. He answers questions
coherently but can be easily distracted by external stimuli. The Client speaks in moderate volume
and rate and appears at ease in producing speech/ words.

Mood and affect:

His mood was stable during the whole duration of interaction. He also exhibited full
range of facial expression congruent to his stories. He laughs when he tells jokes but seems sad
when he talks about his past experiences and problems.

Thought process and content:

He can answer questions immediately and logically but can be inconsistent with some
uttered details. For example, during the first interaction he said that he is already 51 years old but
on the 2nd interaction he claimed to be a 45 y/o guy. The client admits that he is sometimes
preoccupied by the thought that his wife might not love him anymore and finds another partner
because of his current condition (Erotomanic delusions). He is also worried about his children
left at home. In addition, although he is quite stressed of his stay in the psychiatric ward, he is
thinking neither to escape nor attempt a suicide.
Sometimes he uses unusual words that has same sound to substitute real words
(Phonemic) like Strimps for shrimps and Strabs for Crabs.
Sensorium and Intellectual Processes:

The client stated that he has no problem with his other senses except for his blurry vision.
He is oriented with date, place and the persons he is with. He was able to remember the activities
he had done yesterday. “Malagip ku pay laeng dagijay events idi Highschool nak ma’am,” he
added.
Client TM is easily distractible by external stimuli. He frequently shares his observations
on his surroundings even when he is not asked to or if he is in the middle of telling his stories in
the interaction.

Abnormal Sensory experiences or misperceptions:

He admits that he had experienced having auditory hallucinations especially when he

was still in their home, being depressed. “Kanayun adda natagari dijay kisame mi idi nga animals
ma’am isu rinakrak ku ngem awan met ngayam,” he verbalized. Aside from this, he stated that
he hasn’t experienced other types of hallucinations yet.
Client TM is sometimes experiencing delusions or false beliefs. For instance, there was a
part during the conversation where he said that he was once a member of the new people’s army
(NPA) which is untrue.

Judgment and insight:

The client stated that he has some major regrets with his decisions in life. One of which is
the fact that he let himself be discouraged by family problems in attaining his goals.
“Napinpintas met kuma ti panagbiyag mi nu nagadal’ak,” he added. Moreover, he persistently
denies that he is an alcoholic person. According to him, he is only drinking to cope up with his
problems. “Hindi naman ako grabe uminom ng alak, self keeping lang ma’am,” he stated. He
also added that his maximum intake is upto 3 bottles of alcohol (Redhorse) only, thrice a week.
He still blames his father for his misfortunes in life.

Self-concept:

Client Tm considers himself as an independent person. “Uray baybay-an na kami ni

tatang ku idi, kaya’k nga napagbiyag bagbagi’k, nagsapa nak nga nagtrabahu ma’am,” he stated.
Furthermore, he stated that he is easily discouraged by problems in life but he usually draws
consolation and strength from his children and his mother. Aside from drinking alcohol, he also
prays harder whenever he is burdened with trials. Moreover, he also verbalized that usually gets
irritated and annoyed with people who are boastful and “chismosa”.
Client TM mentioned that he doesn’t feel that sense of fulfillment and contentment yet
with his life. “Saka nalang siguro ako makokontento maam ‘pag nakita ko na ang mga anak kong
magtapos ng pag-aaral”, he verbalized. Furthermore, he mentioned that he is not that conscious
about his self. He is contented of how he looks and doesn’t care much about what others think
about him.
The client expressed his concern on his life after discharge from the ward. “Mababainak
tun ma’am syempre baka mabuteng tu dagjay tattau kinyak ta nabagtit’ak,” he verbalized. He
added that he sometimes feel worthless and powerless because of these assumptions.

Role and Relationship:

 Client RM is currently living in Ipil, Echague, Isabela as a farmer, together with his
mother and 3 children. He considers himself as good father and the commander of their house.
“Haan nak agbaba-ut ti ubing ku ma’am, Bagbagaak la isuda nukwa,” he said. Among his 3
children, he is closest with his first child. He stated that he is satisfied with his relationship with
his family and friends. Although, he had some misunderstandings with his father years ago, he
said that he already forgave him for all his faults. Whenever there is misunderstanding in the
family, they manage to talk things through and be alright again.
In addition, he stated that he misses his wife so much who is currently working abroad as
an OFW for 6 years now. “Isun sa pay nagbagbagtitakun, kapapanunut kenyana,” he explained.
Also, one of the events he considers as a factor leading to his current condition is his fight with
his elder sister trying to own his farm land. “Madi dak kayat pagtalunen ma’am, tapus ket bagien
da met ejay daga’k nga 7 hectares’en,” he explained.
Client TM confirms that he haven’t had visitors for the past 6 months of stay in the ward.
He said that though he is quite disappointed, he understands his family for not visiting. “Malayo
kasi ma’am tapos baka nagtatampo na yung mga anak ko sa akin, baka mababain da pay ketdin,”
he stated.

Physiologic and self-care considerations:

In CVMC psyche ward, he eats 3x a day with snacks in between. His meal is commonly
composed of rice, vegetables and meat. He drinks approximately 7 glasses of water daily. He
urinates 8x a day and defecates 1-2x daily. He hasn’t noticed any abnormalities with his urine
and stool. He takes his medicines as prescribed but is experiencing some side effect like breast
tenderness and failure to erect when masturbating.
He is takes a bath with other patients every morning in their oval. And finally, he
commonly doesn’t experience sleep disturbances except when awaken at night due to noise from
other patients.
 VI. COURSE IN THE WARD

ORDERS RATIONALE NURSING RESPONSIBILITY

April 13, 2015, 2: 35 pm
- Please admit to ACIS area
- Secure consent for admission
- IVF: D5NM 1L x 35 gtts/min
- DAT
- Monitor VS q shift and
record
- Routine ward care
DIAGNOSTIC:
For further
assessment/observation and
therapeutic management
For documentation and records
keeping
For hydration and correct
electrolyte imbalances
To aid in the nutritional needs of
patient
To assess patient’s condition and
provide timely intervention on
the occurrence of deviations
To monitor the patient
- Admit the patient as ordered
- Prepare all necessary
documents
- Obtain initial VS
- Notify the designated
department regarding admission
- Assist the patient
-Serve as witness in consent
signing
- Secure consent on chart
- Ensure proper regulation
- Monitor IV site for swelling or
signs of infection
- Check patency
- Instruct the client/SO about the
diet
-Obtain VS as ordered
-Refer relevant findings
accordingly

CBC For diagnosis and determination - Facilitate lab request

of any abnormality in the blood
UA For determination of any
abnormal components such as
protein or microorganisms in the
urine
FA To detect abnormalities in stool
appearance and contents
FBS To monitor deviations in blood
glucose that may pose risk to
health
BUN Measures the amount of
nitrogen in your blood that
comes from the waste product
urea.
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings

Creatinine Measures the level of creatinine - Facilitate lab request

(waste product that forms when
creatine breaks down)in the
blood
Uric acid To determine function of kidney
in eliminating uric acid from
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
 blood
Lipid profile a panel of blood tests that serves
as an initial broad medical
screening tool for abnormalities
in lipids, such as cholesterol and
triglycerides.
Liver profile To assess function of liver in
metabolism of substances e.g.
alcohol and drugs
Serum electrolytes To determine electrolyte
imbalances that may pose risk on
health
12 led ECG  To determine abnormalities
on hearts electrical
conduction system
 Electrolyte imbalances e.g.
hypo/hyperkalemia can
cause cardiac dysrhythmias
Chest X-ray To visualize and detect
abnormalities on the organs in
the thorax
 To monitor and diagnose
possible complications of
prolonged use of alcohol e.g.
cardiac myopathy
THERAPEUTICS: Use to manage signs and
- Risperidone 1tab ODHS symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
Chart ward behavior To monitor patient’s condition
and note any improvement or
worsening of behavior
Suicide/ homicide/ escape To promote safety of the patient
precaution and others
Strap for restlessness PRN To control patient’s behavior
against self and others
- Facilitate lab request
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Remove all jewelries or
metallic objects from
patients body
- Instruct patient to lie still
while procedure is on going
- Obtain ECG
- Refer relevant findings
- Facilitate lab request
- Refer relevant findings
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Observe patient promptly
and document behavior
- Refer accordingly
- Keenly observe and monitor
patient at times
- Remove all things from
patient’s surroundings that
can be used to harm self and
others e.g. knife, ropes,
forks and the likes
- Secure rooms
- Keenly observe patient for
manic behavior
- Help Strap patient if
necessary
April 20, 2015 (10:50 am)
Continue management For continuity of care
May 11, 2015 (1 pm)
Please admit to Male Geria
THERAPEUTICS: Use to manage signs and
- Risperidone 1tab ODHS symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
Chart ward behavior To monitor patient’s condition
and note any improvement or
worsening of behavior
Suicide/ homicide/ escape To promote safety of the patient
precaution and others
Strap for restlessness PRN To control patient’s behavior
against self and others
June 15, 2015 (10:45 am)
THERAPEUTICS: Use to manage signs and
- Risperidone 1tab ODHS symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
- Refer For continues management
July 15, 2015 (9:55 am)
Continue Meds:
- Risperidone 1tab ODHS Use to manage signs and
symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
- Continue management as
ordered
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Observe patient promptly
and document behavior
- Refer accordingly
- Keenly observe and monitor
patient at times
- Remove all things from
patient’s surroundings that
can be used to harm self and
others e.g. knife, ropes,
forks and the likes
- Secure rooms
- Keenly observe patient for
manic behavior
- Help Strap patient if
necessary
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
 alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
- Refer For continues management
August 14, 2015 (10 am)
Continue meds:
- Risperidone 1tab ODHS Use to manage signs and
symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
- Refer For continues management
September 15, 2015 (11 pm)
Continue Meds: Use to manage signs and
- Risperidone 1tab ODHS symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
- Refer For continues management
October 13, 2015 (9:45 am)
Continue meds:
- Risperidone 1tab ODHS Use to manage signs and
symptoms of psychosis
- Clonazepam ½ tab HS Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
- Vit. B complex OD Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
- Refer For continues management
November 12, 2015 (10 am)
Continue meds: Use to manage signs and
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly
-
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly
-
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly
- Ensure proper drug
- Risperidone 1tab ODHS
- Clonazepam ½ tab HS
- Vit. B complex OD
- Refer
symptoms of psychosis
Commonly used to manage
alcohol withdrawal as well as to
relieve anxiety
Used to treat Vit. B deficiency
caused by prolonged use of
alcohol
For continues management
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Ensure proper drug
administration
- Monitor for any adverse
effect of drug to the client
- Refer accordingly

VII. PHYSICAL EXAMINATION

General Appearance:
The client is 5’8’’ in height and has ectomorph in body type. He wears torn short and has no
underwear. He is coherent and aware of the place, time and the persons around him.

AREAS METHOD NORMAL ACTUAL ANALYSIS

USED FINDINGS FINDING
SKIN:
COLOR Inspection light to deep Light Brown Normal
brown

ODOR Inspection no odor Slight body odor d/t poor

hygienic
practices
LESION Inspection no lesion No lesions Normal
TEXTURE Palpation Smooth slightly rough Normal
MOISTURE Palpation Moist slightly dry Normal
TURGOR Palpation/insp when pinched When pinched it Normal
ection should return to return to original
original contour contour rapidly
rapidly
EDEMA Palpation no edema No edema Normal
HAIR:
 COLOR Inspection Black black in color Normal
EVENNESS OF Inspection evenly hair equally Normal
GROWTH distributed distributed
TEXTURE Inspection silky hair Silky Normal
PRESENCE OF Inspection no infestation no infestation Normal
INFESTATION
AMOUNT Inspection equal to amount equal in amount Normal
SCALP:
LESION Inspection no lesion no lesion Normal
CLEANLINESS Inspection Clean Clean Normal

NAILS:
GROOMING Inspection Clean clean both fingers Normal
and toes
CLEANLINESS Inspection Clean Clean Normal
NAILBED COLOR Inspection pink cast in Pinkish Normal
light skinned,
brown/dark
skinned
SHAPE Inspection convex Convex Normal
curvature
TEXTURE palpation Smooth Smooth Normal
CAPILLARY REFILL inspection/palp prompt return 3 seconds until Normal
TEST ation of pink or normal color
usual color returns
SKULL:
SIZE, SHAPE, inspection rounded round and Normal
CONFIGURATION (normocephali symmetric
c and
symmetrical)
MOVEMENT AND palpation smooth, Uniform Normal
MASSES uniform consistency
consistency,
absence of
nodule
FACIAL FEATURES inspection symmetric or Equal in size Normal
slightly a
symmetric
facial features
NODULES palpation no nodule No nodule Normal
DEPRESSION
FACE:
COLOR inspection symmetrical symmetrical Normal
FACIAL inspection symmetrical symmetrical Normal
MOVEMENT
SKIN INTEGRITY Inspection No lesions, No lesions Normal
 smooth
NECK:
SYMMETRY inspection symmetrical symmetrical Normal
LUMPS OR MASSES palpation no masses no masses Normal
RANGE OF MOTION inspection full range of moved head Normal
motion without discomfort
ENLARGEMENT palpation no enlargement no enlargement Normal
TENDERNESS palpation no tenderness no tenderness Normal
EYES:
EYEBROWS inspection hair evenly hair evenly Normal
distributed ; distributed
skin intact
EYEBROWS Inspection symmetrical symmetrical Normal
ALIGNMENT aligned ; equal aligned
movement
CORNEAL REFLEX Inspection light reflection both eyes reflect Normal
TEST is the same on light
EYELIDS Inspection skin intact no skin intact Normal
discharges no
discoloration
ABILITY TO BLINK Inspection 17 blinks 18 blinks Normal

EYELASHES Inspection Equally equally distributed Normal

distributed;
curls slightly
outward
BULBAR Inspection shiny, smooth, Shiny, pink Normal
CONJUNCTIVA pink or red
CORNEAL inspection/palp clients21blinks ability to blinks Normal
SENSITIVITY ation when the touched the cornea
cornea is
touched
PUPILS Inspection black in color transparent and Normal
equal in size shiny
normally 3-7
mm in
diameter
round smooth
boarder
REACTION TO Inspection pupils constrict Pupils constricts Normal
LIGHT
REACTION TO Inspection pupil constrict Pupils constrict Normal
ACCOMMODATION and dilate and dilate
EXTERNAL EAR:
SIZE Inspection equal in size equal in size Normal
POSITION Inspection aligned with aligned with the Normal
the outer outer
DISCHARGES Inspection no discharges no discharges Normal
 LESION Inspection no lesion no lesion Normal
TENDERNESS Palpation no tenderness no tenderness Normal
MOUTH:
COLOR Inspection Pinkish Pink Normal
CONSISTENCY Inspection smooth and Smooth Normal
moist
SYMMETRY Inspection symmetry in symmetrical Normal
contour

THORAX AND
LUNGS
Shape of thorax Inspection Anteroposterio Anteroposterior to Normal
r to transverse transverse
diameter in diameter in ratio
ratio 1:2 1:2
Symmetry Inspection Chest symmetric Normal
symmetric
Breast Palpation Not tender, no Tender Side effect of
mass and antipsychotic
lumps drug
Spinal alignment Inspection Spine Spine vertically Normal
vertically aligned
aligned

uniform temp. Uniform temp.

Chest wall Inspection/ Chest wall intact, Chest wall intact, d/t burn injury
Palpation no tenderness, no no tenderness, s/t excessive
masses, no Keloid (2 inches collagen
lesions below the formation
nipples) during healing
Respiratory excursion Palpation Full and Full and Normal
symmetric chest symmetric chest
expansion expansion
Vocal (tactile) Palpation Bilateral Bilateral Normal
fremitus symmetry of symmetry of
vocal fremitus; vocal fremitus
heard most
clearly at the
apex lungs
Thorax Percussion percussion notes percussion notes Normal
resonates, except resonates
over scapula
Diaphragmatic Percussion Excursion is 3- Excursion is 4 cm Normal
excursion 5cm bilaterally
in women and 5-
6cm in men
Breath sounds Auscultation Vesicular and No adventitious Normal
Broncho breath sounds
 vesicular breath
sounds
Breathing patterns Inspection Quiet, rhythmic Quiet, rhythmic Normal
and effortless and effortless
respiration respiration
Costal angle Inspection Costal angle is Costal angle is Normal
less than 90 less than 90
degrees, and the degrees, and the
ribs insert into ribs insert into the
the spine at spine at
approximately a approximately a
45 degree angle 45 degree angle
Anterior chest Palpation Fully symmetric Fully symmetric Normal
excursion excursion
Trachea Auscultation Bronchial and Bronchial and Normal
tubular breath tubular breath
sounds sounds
THE ABDOMEN Normal
Color Inspection Uniform color Uniform color Normal
Skin integrity Inspection Unblemished Unblemished skin Normal
skin
Contour and symmetry Inspection Flat rounded or Flat Normal
scaphoid,
protuberant
Abdominal Inspection Symmetric Symmetric Normal
movements movements movements
caused by caused by
respiration respiration
Vascular pattern Inspection No visual No visual Normal
vascular pattern vascular pattern
Bowel sounds Auscultation Audible bowel Audible bowel Normal
sounds (20- sounds (20-
30/min) 30/min)
Tenderness Palpation No tenderness, No tenderness Normal
relaxed abdomen
with smooth,
consistent
tension

MINI MENTAL STATUS EXAMINATION (MMSE)

QUESTION PATIENT’S SCORE

1. Ask the patient: Year, Season, Month, Day of Week, Date 5/5
2. Ask the patient: where are we? (Province, Country, City, 5/5
Hospital, Ward)
3. Name 3 objects slowly and clearly then ask the patient to repeat 3/3
them. (Apple, chair, airplane)
4. Spell the word “WORLD” backwards 4/5
5. Recall objects mentioned above 2/3
 6. Point to object and make patient identify them (Ballpen, watch) 2/2
7. Say “no, ifs ,ands or buts” and ask the patient to repeat them 1/1
8. Ask the patient to follow the instructions: Take this paper in your 3/3
right hand, fold it into half, put it on the floor
9. Tell the patient to obey what is written on the paper: “Close your 1/1
Eyes”
10. Give patient a paper and pencil and ask him to write a sentence. 1/1
“here’s a paper and pencil, please write a sentence”
11. Draw intersecting pentagons and ask him to copy it. 1/1
Total Score: 28/30

VIII. ANATOMY AND PHYSIOLOGY

The nervous system is responsible for coordinating all of the body's activities. It controls not
only the maintenance of normal functions but also the body's ability to cope with emergency
situations.

Function

The nervous system has three general functions: a sensory function, an interpretative function
and a motor function.

1. Sensory nerves gather information from inside the body and the outside environment.
The nerves then carry the information to central nervous system (CNS).
2. Sensory information brought to the CNS is processed and interpreted.
3. Motor nerves convey information from the CNS to the muscles and the glands of the
body.

Structure

The nervous system is divided into two parts:

1. The central nervous system consisting of the brain and spinal cord. These structures are
protected by bone and cushioned from injury by the cerebrospinal fluid (CSF)
2. The peripheral system which connects the central nervous system to the rest of the body.
Central nervous system

These structures are protected by bone and cushioned from injury by the cerebrospinal fluid
(CSF).

Brain

The brain is a mass of soft nerve tissue, which is encapsulated within the skull. It is made up of
grey matter, mainly nerve cell bodies, and white matter which are the cell processes. The grey
matter is found at the periphery of the brain and in the centre of the spinal cord. White matter is
found deep within the brain, at the periphery of the spinal cord and as the peripheral nerves.

Parts of the Brain:

 Cerebrum - the largest part of the brain. It is the centre for thought and intelligence. It is
divided into right and left hemispheres. The right controls movement and activities on the
left side of the body. The left controls the right side of the body. Within the cerebrum are
areas for speech, hearing, smell, sight, memory, learning and motor and sensory areas.
 Cerebral cortex - the outside of the cerebrum. Its function is learning, reasoning,
language and memory.
 Cerebellum - lies below the cerebrum at the back of the skull. Its functions are to control
voluntary muscles, balance and muscle tone.
 Medulla - controls heart rate, breathing, swallowing, coughing and vomiting. Together
with the pons and the midbrain, the medulla forms the brainstem that connects the
cerebrum to the spinal chord.
 Meninges- The bony covering around the brain is called the cranium, which combines
with the facial bones to create the skull. The brain and spinal cord are covered by a tissue
known as the meninges, which is made up of three layers: dura mater, arachnoid layer,
and pia mater. The dura mater is a whitish and non-elastic membrane which, on its outer
surface, is attached to the inside of the cranium. This layer completely covers the brain
and the spinal cord and has two major folds in the brain, that are called the falx and the
tentorium. The falx separates the right and left halves of the brain while the tentorium
separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane
that covers the entire brain and is positioned between the dura mater and the pia mater,
and for the most part does not follow the folds of the brain. The pia mater, which is
attached to the surface of the entire brain, follows the folds of the brain and has many
blood vessels that reach deep into the brain. The space between the arachnoid layer and
the pia mater is called the subarachnoid space and it contains the cerebrospinal fluid.
 Ventricles: Brain ventricles are a system of four cavities, which are connected by a series
of tubes and holes and direct the flow of CSF within the brain. These cavities are the
lateral ventricles (right and left), which communicate with the third ventricle in the center
of the brain through an opening called the interventricular foramen. This ventricle is
connected to the fourth ventricle through a long tube called the Cerebral Aqueduct. CSF
then exits the ventricular system through several holes in the wall of the fourth ventricle
(median and lateral apertures) after which it flow around the brain and spinal cord.
 Brainstem: The brainstem is the lower extension of the brain which connects the brain to
the spinal cord, and acts mainly as a relay station between the body and the brain. It also
controls various other functions, such as wakefulness, sleep patterns, and attention; and is
the source for ten of the twelve cranial nerves. It is made up of three structures: the
 midbrain, pons and medulla oblongata. The midbrain is involved in eye motion while the
pons coordinates eye and facial movements, facial sensation, hearing, and balance. The
medulla oblongata controls vegetative functions such as breathing, blood pressure, and
heart rate as well as swallowing.
 Thalamus: The thalamus is a structure that is located above the brainstem and it serves
as a relay station for nearly all messages that travel from the cerebral cortex to the rest of
the body/brain and vice versa. As such, problems within the thalamus can cause
significant symptoms with regard to a variety of functions, including movement,
sensation, and coordination. The thalamus also functions as an important component of
the pathways within the brain that control pain sensation, attention, and wakefulness.

 Lobes: The frontal lobes are responsible for voluntary movement, speech, intellectual
and behavioral functions, memory, intelligence, concentration, temper and personality.
The parietal lobe processes signals received from other areas of the brain (such as
vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The
occipital lobe is responsible for processing visual information. The temporal lobe is
involved in visual memory and allows for recognition of objects and peoples' faces, as
well as verbal memory which allows for remembering and understanding language.
 Hypothalamus: The hypothalamus is a structure that communicates with the pituitary
gland in order to manage hormone secretions as well as controlling functions such as
eating, drinking, sexual behavior, sleep, body temperature, and emotions.
 Pituitary Gland: The pituitary gland is a small structure that is attached to the base of
the brain in an area called the sella turcica. This gland controls the secretion of several
hormones which regulate growth and development, function of various organs (kidneys,
breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the
adrenal glands).
 Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus which
are heavily connected to the cells of the cerebral cortex. The basal ganglia are associated
with a variety of functions, including voluntary movement, procedural learning, eye
movements, and cognitive/emotional functions. The various components of the basal
ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and
subthalamic nucleus. Diseases affecting these parts can cause a number of neurological
conditions, including Parkinson's disease and Huntington's disease.
 Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as
compared to spinal nerves that initiate in the spinal cord. These nerves are responsible for
specific activities and are named and numbered as follows:
- Cranial nerve I (Olfactory nerve): Smell
- Cranial nerve II (Optic nerve): Vision
- Cranial nerve III (Oculomotor nerve): Eye movements and opening of the
eyelid
- Cranial nerve IV (Trochlear nerve): Eye movements
- Cranial nerve V (Trigeminal nerve): Facial sensation and jaw movement
- Cranial nerve VI (Abducens nerve): Eye movements
- Cranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste
sensation
- Cranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balance
- Cranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowing

- Cranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensation
 - Cranial nerve XI (Spinal accessory nerve): Control of neck and shoulder -
muscles
- Cranial nerve XII (Hypoglossal nerve): Tongue movement

The spinal cord

The spinal cord is about 45 cms long, extending from the medulla down to the second lumbar
vertebrae. It acts as a message pathway between the brain and the rest of the body. Nerves
conveying impulses from the brain, otherwise known as efferent or motor nerves, travel through
the spinal cord down to the various organs of the body. When the impulses reach the appropriate
level they leave the cord to travel to the' target organ.

Sensory or afferent nerve impulses also use the spinal cord to travel from various parts of the
body up to the brain.

Peripheral system

The peripheral system connects the central nervous system to the rest of the body. The main
divisions of the Peripheral Nervous System are:

 The autonomic nervous system — which controls the automatic functions of the body:
the heart, smooth muscle (organs) and glands. It is divided into the Sympathetic-“fight-
or-flight” system and the Parasympathetic-“resting and digesting" system.
 The somatic nervous system — which allows us to consciously or voluntarily control our
skeletal muscles. The somatic system contains 12 cranial nerves and 31 spinal nerves.
 Nerves — which are made up of special cells called neurons. Neurons are comprised of a
dendrite, a cell body and an axon. Impulses travel to the dendrite into the cell body and
then onto the axon. A special sheath called myelin, which increases the conductivity of
the neuron, covers some nerves.

As messages travel from one neuron to the next they move across a synapse. At each synapse
there is a chemical called a neurotransmitter. At various parts of the body specific
neurotransmitters facilitate communication, for example dopamine (motor function), serotonin
(mood) and endorphins (painkillers). Sensory neurons carry messages from a receptor to the
brain. The brain then interprets the message. Motor neurons then send the message to an affector
in muscles and glands.

Receptor (sensory organ) sends a signal to the sensory neuron which sends a signal to the
brain/spinal chord which sends a signal to the motor neuron which sends a signal to the affector
(muscle/gland).

The Neuron

The basic unit of the nervous system, is a specialized cell called the neuron. These nerve cells
make up a massive network of specialized cells that transmit messages, very rapidly, from one
part of the body to another. Information is transmitted via electrical impulses.
The neuron is comprised of a nerve cell and its adjoining processes called an axon and dendrites.
Every nerve cell has one or more processes attached to it. Electrical impulses enter the neuron
via the dendrites and leave via the axon. The space between the axon of one cell and the
dendrites of another is called a synapse. Specialized chemicals called neurotransmitters help
conduct impulses through the synapse onto the next cell.

IX. LABORATORY RESULTS

FLUID SERUM
April 14, 2015
TEST NORMAL RANGE RESULT ANALYSIS
Glucose 4.10-5.90 mmol/L 4.5 mmol/L d/t inadequate intake of
carbohydrate-rich foods
and fluids
Urea 2.50-7-10 mmol/L 2.58 mmol/L Normal
Creatinine 53.0 – 115.0 mmol/L 85.40 umol/L Normal
Uric Acid 149-506 umol/L 341. 9 umol/L Normal
AST 14-59 U/L 28 U/L Normal
ALT 9-72 U/L 32 U/L Normal
Cholesterol 3.99 mmol/L 3.99 mmol/L Normal
Triglycerides 1.0-1.69 mmol/L 0.45 mmol/L Normal
Direct HDL 1.0-1.60 mmol/L 1.45 mmol/L Normal
LDL 1.0-3.35 mmol/L 2.14 mmol/L Normal
Total protein 63-82 g/L 71 g/L Normal
Albumin 35-50 g/L 40 g/L Normal
Globulin 23- 35 g/L 25 g/L Normal
A/G Ratio 1.5-2.5 g/L 1.7 g/L Normal

HEMATOLOGY
April 14, 2015

TEST NORMAL RANGE RESULT ANALYSIS

Hgb 120-160 g/L 128 g/L Normal
Hct 0.38-0.47 g/L 0.376 g/L Normal
RBC ct. 4.5-6.0 x10^12/L 4.50x10^12/L Normal
aPC 150-400x10^9/L 260x10^9/L Normal
MCV 80-100fL 83.5fL Normal
 MCH 26-32 g 28.4g Normal
MCHC 320-360g/L 341g/L Normal
WBC 4.5-11 x10^g/L 4.6 x10^g/L Normal
Differential Count
Neutrophils 35-65 % 57.9 % Normal
Lymphocytes 20-40 % 34.1 % Normal
Monocytes 2-8 % 2.2 % Normal
Eosinophils 0-5 % 4% Normal
Basophils 0-1 % 0.4 % Normal

CHEST PA
April 16, 2015
Interpretation:
Lung fields are clear
Normal heart size
Other chest structures are intact

Impression:
Normal chest finding

ECG

April 16, 2015

Impression:
Normal Sinus Rhythm

PARASITOLOGY RESULT FORM

April 20, 2015

Color: Brown
Consistency: Semi-formed
Parasite: No Ova of Parasite seen
Bacteria: 2+

Analysis:
Normal
Urinalysis Result Form
April 16, 2015
Physical Analysis
Color : Yellow Normal
Transparency : Clear Normal
Ph : 6.5 (acidic) Normal
Specific Gravity : 1.020 Normal

Chemical Tests Analysis

Albumin
Negative Normal
Sugar
Ketone : Negative Normal
Blood : Negative Normal
Bilirubin
Urobilinogen
Nitrite Negative Normal
Leukocytes

Microscopic Result Analysis

Exam
Leukocytes : Negative Normal
Erythrocytes : Negative Normal
Epithelial cells : Negative Normal
Bacteria : Few Bacteria from the external structures may
contaminate urine (d/t poor hygiene and self-
care deficits)

XI. NURSING CARE PLAN

Assessment:
 Subjective - “Haan nak met grabe nga uminum ti arak ma’am, self-keeping lang,” TM
stated
 Objective – use of manipulative behavior to avoid the topic, poor eye contact, Projection
of blames for problems

Diagnosis:
 Denial r/t effects of substance abuse

Planning:
 At the end of the interaction the patient will be able to verbalize awareness of relationship
of substance abuse to current situation and accept responsibility with own actions
 Intervention
1. Conveyed attitude of acceptance,
separating individual from
unacceptable behavior
2. Answered questions honestly and
provide factual information
3. Provided information on the effects
of substance abuse on mood,
personality and way of life
4. Discussed current situation and
allowed expression of feelings
5. Confronted and examined denial
and rationalization
6. Kept alert for signs and symptoms
of mood changes
7. Taught patient on anxiety –
reducing strategies e.g. deep
breathing exercises and reflecting
8. Encouraged and supported
individual in taking responsibility
for own recovery e.g. using other
alternative behavior besides
drinking alcohol to cope up with
stress
Rationale
Promote feelings of dignity and self-worth
Creates a trusting relationship
Individuals often mistake effects of
addiction and use this to justify and
excuse drug use
Allows patient to see relationship between
substance abuse and personal problems
Caring attitude preserves self-concept and
decrease defensive mechanism
Confrontation can cause agitation and
may compromise safety of patient and
staff
Anxiety –reducing strategies may
diminish use of denial and may improve
compliance with therapy
Denial can be replaced with positive
action when the patient accepts the reality
of own responsibility

Evaluation:

Assessment:
 Subjective - “Mababainak talaga ti dadduma nga tao ma’am, baka mabuteng da
kinyakun,” TM stated
 Objective – use of manipulative behavior to avoid the topic, poor eye contact, Shifted
position to close posture (bowing)

Diagnosis:
 Low self-esteem r/t social stigma attached to substance abuse

Planning:
 At the end of the interaction the patient will be able to:
 verbalize acceptance of self and increase sense of worth
 Participate in social activities in his community
 Intervention
1. Encouraged verbalization of feelings
on current situation
2. Spent time with patient to discuss
patients behavior and use of
substance abuse in a non-judgmental
way
3. Provided reinforcements for positive
actions
4. Encouraged expression of guilt,
shame and anger
5. Asked patient to review past
accomplishments
6. Assisted client to identify goals that
are personally achievable e.g.
limiting alcohol intake at home
7. Involve patient in activities e.g.
parlor games or exercise programs
Rationale
Patient often has difficulty accepting
degree of importance the substance has
assumed in his life and its relationship to
the situation
Nurse’s presence conveys acceptance of
an individual as worthy person thus
increasing self-esteem
Allows patient to accept self as an
individual positive attitudes
Allows patient to accept responsibility for
self and take steps to make changes
Allows patient to determine his strengths
and positive attributes
Increases likelihood of success and
commitment to change
Promotes socialization and enhances sense
of well-being that can help energize client

Evaluation:

Assessment:
 Subjective - “Agin-inumak tapnu malipatak problemak ma’am,” TM stated
 Objective – use of manipulative behavior to avoid the topic, poor eye contact, previous
history of alcohol abuse
Diagnosis:
 Ineffective Coping r/t use of

Planning:
 At the end of the interaction the patient will be able to realize and identify ineffective
coping behavior and be knowledgeable with other coping strategies

Intervention Rationale
1. Provided safe-non threatening Encourages patient to talk freely without
environment fear of judgment
2. Determined understanding of current Allows client to express degree of denial,
 situation,previous and other methods
of coping with life’s problems
3. Encouraged verbalization of
feelings, fears and anxiety
4. Explored alternative coping
strategies e.g. playing guitar or
talking with his close friends about
his problems
5. Assisted patient to learn and
encouraged use of relaxation skills
e.g. playing music and taking deep
breaths when anxious
6. Encouraged participation in art
therapy and music therapy
acceptance of personal responsibility and
commitment to change
Helps client to come with terms with long
unresolved issues
Patient needs to know more about other
options/ adaptive response for managing
time, feelings and relationship without
drugs
Helps patient to relax and develop new
ways to deal with stress, problem solving
Serves as divertional activities against
substance cravings

Evaluation:

Goal met as manifested by the following:

 “ Arak ti mangdadael kinyak ken ti pamilyak,” TM stated
 Patient was able to understand other coping strategies e.g. talking to someone or playing
music instead of drinking alcohol

Assessment:
 Subjective - “ Agiginura kam nga agkakabsat mi, 6 months pay ketdin nga awan
mangbibisita kinyakun ta adayu ken agtamtampo dagijay anak kun,” TM stated
 Objective – poor eye contact, manipulative behavior, expression of shame and doubt

Diagnosis:
 Dysfunctional Family Process r/t substance abuse and current psychiatric condition

Planning:
 At the end of the interaction the patient will be able to verbalize a desire to improve
relationship

Intervention Rationale
1. Determined make-up of family, To identify factors that can strain the
length of relationship, financial relationship between family members
 situation
2. Discussed patient perception of own
need and member’s needs
3. Ascertained ways in which his
family deals with conflicts
4. Encouraged verbalization of feelings
and emotions about the relationship
5. Discussed surface symptoms of
dysfunctional relationship e.g.
ignoring each other without
confrontation and the fact that these
are not the problems that needs to be
focused with
6. Provide information about active
listening techniques
7. Promote non-blameful self-
disclosure
To identify problems that needs attention
and solution
To identify ineffective coping strategy of
family
To assess satisfaction on relationship with
others
Individuals are often unaware of the
underlying emotions that are influencing
their behavior and continue to focus on
surface symptoms
Avoid giving advices and encourages the
client to find own solution, enhancing self-
esteem
Can result in a more considerate and
respectful resolution

Evaluation:

Assessment:
 Risk factors: history of substance abuse, male gender, pharmaceutical agents
(psychoactive drugs), metabolic abormalities

Diagnosis:
 Risk for acute confusion

Planning:
 At the end of the interaction the patient will be able to understand risk factors and
maintain normal level of consciousness and cognition.

Intervention Rationale
 1. Identified factors present such as
substance abuse, trauma, etc.
2. Determined clients functional level
including ability to do ADLs and
move about at will.
Acute confusion is a symptoms r/t and
associated with numerous causes
Conditions and situations that limits
patient’s mobility and independence
potentiates prospect of acute confusion
state

3. Oriented patient to surroundings, To promote and increase patient’s

staff and necessary activities awareness
4. Maintained calm environment To help patient relax and avoid
overstimulation
5. Encouraged participation of To enhance well-being and keep patient’s
activities and therapies mind active
6. Assisted with treatment of To lessen risk factor
underlying problem
7. Emphasized importance of ongoing To limit possibility of misuse for potential
monitoring of medications adverse effects

Evaluation:
 Goal met as manifested by:
- Patients understanding of own risk factors
- Patient was able to maintain mood, LOC during the entire duration of the interaction

XII. DRUG STUDY

Doctor’s Order  Risperidone 1 tab ODHS
Generic name  Risperidone
Brand name  Risperdal
Classification  Atypical Antipsychotic
Action  Blocks dopamine and 5HT2 receptors in the brain
Indication  Used to treat signs/ symptoms of psychosis
Contraindication  Contraindicated in patients hypersensitivity to drug
 Cautiously in patients with prolonged QT interval and CVD
 Hepatic and renal impairment
Adverse effect  Akathisia, somnolence, pain, anxiety, headache, suicide
attempt, NMS, fever malaise,Tachycardia, chestpain,
hypotesion, edema, syncope, rhinitis, sinusitis, vision and ear
 disturbances
Nursing consideration  Monitor sugar level (increased risk for hyperglycemia)
 Assess renal and hepatic function
 Monitor weight gain
 Be alert for signs of reactions and drug
 Inform patient to limit activities after intake, dizziness may
occur

Doctor’s Order  Clonazepam ¼ tab HS

Generic name  Clonazepam
Classification  Anxiolytics
Action  Potentiates the effect of GABA (neurotransmitter that
modulates other neurotransmitters)
Indication  Used to treat and lessen anxiety
 Promotes safe alcohol withdrawal
Contraindication  Contraindicated in patients hypersensitivity to drug
 Cautiously in patients in acute alcohol intoxication w/
depression of VS
 Contraindicated for patients with narrow-angled glaucoma, in
shock and coma
 Hepatic and renal impairment
Adverse effect  Sedation, depression, hypomania, disorientation, CV collapse,
bradycardia, tachycardia, inc. BP, edema, Auditory and visual
hallucinations, diplopia, nystagmus, constipation, dry mouth,
n/v, encoporesis
Nursing consideration  Instruct to avoid alcohol, sleep inducing and over-the-counter
drugs while taking the medication
 Assess renal and hepatic function
 Be alert for signs of reactions and drug

Doctor’s Order  Vit. B complex OD

Generic name  Vitamin B complex
Classification  Supplement
Action  A coenzyme that stimulates metabolic function and is needed
for cell replication, hematopoiesis, nucleoprotein and myelin
synthesis
Indication  For vit. B defiency caused by chronic alcoholism
Contraindication  Hypersensitivity
Adverse effect  Peripheral vascular thrombosis, heart failure, transient
diarrhea, pulmonary edema, itching, anaphylaxis
Nursing consideration  Assess and confirm reticulocyte count, haematocrit, Vit. B 12,
iron folate before beginning the therapy
 Avoid IV administration
 Avoid giving large doses of B12
 Protect drug from light, do not refrigerate or freeze
 Monitor for adverse effects

XIII. REFERENCES

Websites:
[Current peculiarities of alcoholic psychosis]. - PubMed - NCBI
Acute alcoholism | definition of acute alcoholism by Medical dictionary
Alcohol | SAMHSA
Alcohol Dependence And Withdrawal - Care Guide
Alcohol use disorder Symptoms - Mayo Clinic
Alcoholism Series: What is Alcoholic Psychosis?
Alcohol's Effect On The Body: 5 Majors Organs That Are Being Destroyed By Your Alcohol
Consumption
Anatomy & Physiology - Nervous System
Chronic alcoholism | definition of chronic alcoholism by Medical dictionary
Diagnostic criteria for Substance-Induced Psychotic Disorder | BehaveNet
Psychiatric Presentations of Medical Illness | Alternative Mental Health
The Science of Drug Abuse and Addiction: The Basics | National Institute on Drug Abuse (NIDA)
Hematology | Johns Hopkins Medicine Health Library
www.scribd.com

Books:
Psychiatric Mental Health Nursing, Sheila L. Videbeck, 5th edition
Nursing Diagnosis Manual, Doenges/Moorhouse/Murr