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Republic of the Philippines NORTHERN NEGROS STATE COLLEGE OF SCIENCE & TECHNOLOGY
Old Sagay, Sagay City, Negros Occidental (034)722-4120/www.nonescost.edu.ph
CERTIFICATENUMBER:AJA12.0653
HILDEGARD PEPLAUS INTERPERSONAL RELATIONS THEORY IN ITS RELEVANCE IN
A BIPOLAR PATIENT
A CLINICAL RESEARCH PAPER
Presented to
The Faculty of the Graduate School NORTHERN NEGROS STATE COLLEGE OF SCIENCE AND TECHNOLOGY
Old Sagay, Sagay City, Negros Occidental
In Partial Fulfillment Of the Requirements for the Degree
MASTER in NURSING major in NURSING MANAGEMENT AND ADMINISTRATION
By
TIFFANY ALTEZA C. UNTAL, R.N.
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ACKNOWLEDGEMENT
This clinical research paper would not be accomplished without the assistant and encouragement, support and guidance of several people whom I am forever indebted with.
First I would like to thank God for bestowing me the
blessings and a beautiful mind even if at times it might be such a wonderful mess. Without such Omnipotent Grace, none of these are possible.
To my ever-loving family, friends and dear mentors for
their unyielding support upon my venture in finishing this paper I salute your ever steadfast confidence you have given me despite of my frailties and shortcomings upon accomplishing this task.
My deepest gratitude to the Negros Occidental Drug
Rehabilitation Foundation, Inc. (NODRFI) staff especially to Dr. Ernesto A. Palanca and Ms. Juvy A. Pepello for allowing me to discover the struggles and beauty, triumph and despair as well as the magnificence of the human mind that had been the source of hope and motivation of the restoration and inspire rehabilitation. Thus, the essential existence of the institution.
And lastly, I dedicate this paper as a tribute to the
patient and to those who are suffering the same ailment. May this paper serve as a penchant of hope that all is not lost; an affirmation that you have capabilities in determining the course of your own destiny. Thank you for trusting me and sharing with me the fragile yet intricate longings, beautiful yet forlorn dreams and allowing me to impart and to take a glimpse in your battles with loneliness and despair. May you find your inner purpose that will motivate you to be a blessing in humankind and accept your condition as a gift rather than a curse, making most of lifes clashing ironies into magnificent symphony.
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TABLE OF CONTENTS
Page Title Page i Approval Sheet ii Table of Contents iii List of Tables iv List of Figures v
Chapter I Introduction
Background of the Study 1 Statement of the Problem 3 Significance of the Study 4
Chapter II Review of Related Literature
Conceptual Framework 22 Assumption 26 Definition of Terms 26
Chapter III Application of Nursing Process
Findings Conclusion Recommendation References Appendices
Patients Profile 28 Clinical History 28 Patients Anamnesis 29 NPI 38 Methodology Assessment Tool 43 Scoring and Interpretation 46
The Nursing Process Assessment Phase 43 Planning Phase 48 Implementation Phase 54 Evaluation Phase 58
- Appendix A: Letters - Appendix B: Assessment Tool - Appendix C. NCP -
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List of Tables Table Page
1 Initial Assessment Score 45
2 Nursing Care Plan 48
3 Monitoring Chart 49
4 Final Assessment Score 56
5 Mean Difference Between 56
The Initial and Final Assessment
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List of Figures
Figures Page
1 Schematic Diagram of Peplaus 27 Interpersonal Relations Theory: Conceptual Framework
2 Evaluative Scale 46
3 Initial Evaluative Scale of Mean 46
4 Final Evaluative Scale of Mean 47
5 Comparative Level of Loneliness Tendency 57
Between The Initial and Final Assessment Result
7 Comparative Level of Initial and 57
Final Assessment in Chart
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CHAPTER I INTRODUCTION
Moods are typically transient things that shift from moment
to moment or day to day. While people's moods rise and fall,
most of it never become that extreme or uncontrollable. As
depressed as an average person might get, it won't take too much
for them to recover and start feeling better. Similarly, happy
and excited moods are not easily sustainable either, and tend to
regress back to a sort of average mood.
At times, emotions could stir an artistic drive that
creates a marvelous passion. Yet, sometimes it is deeply rooted
on a more serious pathology. It generates a fire that
potentiates an individual to be motivated or it personifies a
force to led life to a deeper essence. However to certain
people, it is the same fire that burns. Taming emotions takes a bit of mastery; but for them, it is already a major life battle
wherein their sanity priced the cost.
We all have monsters inside our head; Although a few lived
by their own demons and can no longer control their own sense of
self-integrity. These fellows need more attention; their
eccentricities and outbursts already a call for help. They could
be a stranger, a passerby, a neighbor, a friend, a family, or it
might had already been you.
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Society itself held the stigma and biases to this persons
instead of understanding and support. These individuals actually
scream for help within their own inner dilemma. And if these
submerged implosions and rage be not sufficed to induce violence
with themselves, it eventually explodes into a violence toward
others.
This clinical paper had been brought forth to determine the
effectiveness of Nurse-Patient interaction and Nursing
intervention utilizing Hildegard Peplaus Interpersonal
Relations Theory wherein significant roles of a nurs is being
acted in promotion if not for the full-recovery, at least the
rehabilitation or even just the alleviation of symptoms
characterized by these patients having mental illness as
characterized in the change of attitude and disease adaptation
by helping them recover self-integrity in the discernment that
they are more than just the symptoms of their illness. Statement of the Problem
Is there a change in the level of loneliness tendency when
Peplaus Interpersonal Relations Theory is utilized together
with the nursing process in the management of Bipolar.
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3Significance of the Study
Patient. That he/she would gradually identify the root of his/her own disorder and imbue learning while encourage
awareness and hope to recovery and progressively be the
inspiration and becoming an advocate to the youth unto
which act as a guide not to led astray.
Family. That each member will cultivate awareness and
instead of blame, anger and despair nurture understanding,
patience, compassion instead and inner growth in
understanding the patient and serve as a strong support
system to the recovery of the patient.
Health Provider/Rehabilitation Staff. That it would instill
resonance of learning and progression in profession not
only as a mental health nurse but by applying the theory in
each patients that he/she would come across into promoting
health, imparting social deliverance and render baggage
unburdening towards the holistic recovery of patients. And
Health and Social Programs for children, youth and families
should take on a forward- thinking and holistic approach;
services and programs should be available.
Community. That the community would gradually understand and
have a grasp of knowledge concerning substance abuse and
drug addiction, perception of the mentally deranged as well
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of those who had been rehabilitated. The study also strive
to reach out awareness to the cause, effect and prevention
of factors that would lead to rehabilitation and not just a
casual cultural clich that each member of the society
could partake in collaboration into the nurses different
role to further advance recovery of the patients and
gradually to the interaction of the patient post
rehabilitation.
Future researchers. The results of this study will serve
as a reference material for those who would like to conduct
further study on similar topics.
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CHAPTER II
REVIEW OF RELATED LITERATURE
In contrast to people who experience normal mood
fluctuations are people who have Bipolar Disorder. People with
bipolar disorder experience extreme and abnormal mood swings
that stick around for prolonged periods, cause severe
psychological distress, and interfere with normal functioning.
Most people can't stay too depressed or too happy for any length of time. A study suggests that emotional pain lasts for
12 minutes, anything longer than that is considered to be self-
inflicted as it shows people would rather inflict pain on
themselves than spend 15 minutes with their own thoughts
(Sheridan, 2014).
Bipolar Disorder (also known as Manic-Depression, or sometimes Bipolar Affective Disorder), is a category of serious
mood disorder that causes people to swing between extreme,
severe and typically sustained mood states which deeply affect
their energy levels, attitudes, behavior and general ability to
function. Bipolar mood swings can damage relationships, impair
job or school performance, and even result in suicide. Family
and friends as well as affected people often become frustrated
and upset over the severity of bipolar mood swings.
Bipolar moods swing between 'up' states and 'down' states.
Bipolar 'up' states are called Mania, while bipolar 'down'
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6states are called Depression. Mania is characterized by a
euphoric (joyful, energetic) mood, hyper-activity, a positive,
expansive outlook on life, an inflated sense of self-esteem or
grandiosity (a hyper-inflated sense of self-esteem), and a sense
that most anything is possible.
Depression is, more or less, the opposite mood state from mania. Depression is characterized by feelings of lethargy and lack of energy, a negative outlook on life, low or non-existent
self-esteem and self-worth, and a sense that nothing is
possible. Depressed individuals tend to lose interest in things
that used to give them pleasure and enjoyment (such as sex, food or the company of other people). They may sleep too much or too
little. Regardless of how much sleep they actually get, they
tend to complain about feeling constantly tired and fatigued.
Their mood tends to be dysphoric (e.g., distressed, negative,
unhappy), although they may experience dysphoria in different
ways. Such negative feeling states help depressed people lose
confidence in their abilities, become pessimistic about their
futures, and (sometimes) conclude that life is no longer worth
living.
Interpersonal theory and interventions are useful for
patients with a wide variety of diagnostic labels, including
schizophrenia, depression, mood disorders, borderline
personality disorders, and mild mental retardation. These
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7interventions are useful both in one-to-one therapeutic
relationships and milieu interventions. The theory and
interventions provide an effective adjunct for
psychopharmacology and psychiatric rehabilitation, particularly
with people who have complex behavioral problems refractory to
psychopharmacological intervention.
Cacioppo and Hawkley (2010) have hypothesized that lonely
people are hyper-vigilant to social threat linking this bias
specifically to threats of social rejection or social exclusion.
This could mean that lonely people in their everyday lives (1)
fail to make accurate appraisals of social events, such that
they misinterpret social events negatively, but also (2) that
they have visual attention biases, such that they are on the
lookout for negative social events so that they can avoid them
and protect themselves against psychological pain.
According to the Canadian Nurses Association, psychiatric nurses must be knowledgeable in the areas of biological and
psychological theories of mental health and mental illness,
psychotherapy, substance abuse, care of populations at risk, the
community as a therapeutic milieu, cultural and spiritual
implications of nursing care, psychopharmacology and
documentation specific to the care of the mentally ill. Skill
competency stresses comprehensive bio-psychosocial assessment,
interdisciplinary collaboration, identification and coordination
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8of resources for offenders and families, the use of psychiatric
diagnostic classification systems, therapeutic communication,
establishing therapeutic relationships, therapeutic use of self,
psycho-education with clients and administering and monitoring
psychopharmacologic agents.
Recovery has been defined as a process of healing and transformation that results in the ability to achieve full
potential in living a meaningful life (Substance Abuse and
Mental Health Services Administration [SAMHSA], 2013). It
includes healing processes such as self-direction,
individualized and person-centered care, empowerment, holistic
recovery, strengths-based care, mutuality, respect, and
responsibility (SAMHSA, 2013). Person (patient)-centeredness is
one of multiple processes that support recovery.
Psychiatric nursing practice is rooted in the healing power
of the interpersonal nurse-patient relationship, as described by
Hildegard Peplau (Howk, 2012), an early leader in the
development of modern psychiatric nursing. Nurses generally
agree that nursing practice should be patient centered in the
sense that effective working relationships are formed with
patients to provide nursing care that incorporates an
understanding of the patients perspective. Beyond patient-
centeredness, psychiatric nurses view nursing care as helping
patients work through mental health concerns that are marked by
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9anxiety and non-adaptive coping behaviors, to achieve mental
health recovery.
Dr. Hildegard Peplau introduced an interpersonal relations
paradigm for the study and practice of nursing in the late 1940s
and early 1950s (Rust, 2012). Her theory is one of the early
Nursing theories, published in 1952. The paradigm evolved from
her work with H. Sullivan, E. Fromm, F. Fromm-Reichmann, other
eminent clinicians, and her experience working with seriously
mentally ill patients in public and private psychiatric
hospitals. Her Interpersonal Relations Theory has had particular
relevance and usefulness in understanding and intervening to
reduce symptoms, re-establish relatedness, restore a sense of
self-identity, improve function, and promote health.
Peplau's Interpersonal Relations Theory describes
psychiatric nursing roles in terms of the position which the
nurse assumes during the various phases of the nurse-client
relationship. The client is defined as an individual rather than
a community or group. Dr. Peplau's scope of influence goes far
beyond the field of psychiatric mental health nursing. She
advanced nursing professional, educational, and practice
standards and stressed the importance of professional self-
regulation through credentialing. For her, the key question was:
What do nurses know and how do they use that knowledge to
benefit people? (Rust, 2012).
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The nurse-patient relationship consists of four steps
(orientation, identification, development and conclusion). In
these steps nurse could have the role of foreign, reliable
person, teacher, guide in nursing care, substitute and
consultant. Nurse-patient relationship is influenced by
psychobiological experiences (needs, frustrations, conflicts and
anxiety) which need dynamism. Peplau thinks that Nursing care is
an important opportunity for nurse because she can help patient
to complete the infancy psychological tasks (learning to rely on
other people, learning to show satisfaction, self-identifying,
and developing ability in sharing) if these are not completed.
For these reasons Nursing, by Peplau, is a maturation strength
of civilization (Dussault, 2014).
As many as 5 million adolescents suffer from clinical
depression, but according to a 2009 study, an estimated 70
percent are undiagnosed and dont receive any form of treatment.
Without treatment, a depressed teen may turn to alcohol or drugs
to escape their feelings of helplessness or to help them feel
normal. Unfortunately, drug and alcohol use only worsens
depression symptoms (Drug Abuse and Depression in Teens, 2010).
Adolescence, by definition, is a time of risk takingbrain
imaging has shown us that teens are hard-wired to take more
chances as the parts of the brain that generate ideas and make
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11decisions continue to mature and grow. (Drug Abuse and
Depression in Teens, 2010).
Many aspects of this phase of brain development are
beneficial, allowing teens to be creative and flexible in their
thinking, and helping them to hone in on the pursuits they are
passionate about. On the flip side, this risk-taking phase of
development also makes teens vulnerable in ways that have the
potential for harm and long-term problems.
Interpersonal theory and interventions are useful for
patients with a wide variety of diagnostic labels, including
schizophrenia, depression, mood disorders, borderline
personality disorders, and mild mental retardation (Rust, 2012).
These interventions are useful both in one-to-one therapeutic
relationships and milieu interventions. The theory and
interventions provide an effective adjunct for
psychopharmacology and psychiatric rehabilitation, particularly with people who have complex behavioral problems refractory to
psychopharmacological intervention.
Bipolar disorder, also known by its classic name "manic
depression," is a mental disorder that is characterized by
serious mood swings. A person with bipolar disorder experiences
alternating highs (what clinicians call mania) and lows
(also known as depression). Both the manic and depressive
periods can be brief, from just a few hours to a few days, or
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12longer, lasting up to several weeks or even months (Cacioppo, et
al.2013).
A manic episode is characterized by extreme happiness,
extreme irritability, hyperactivity, little need for sleep
and/or racing thoughts, which may lead to rapid speech. A
depressive episode is characterized by extreme sadness, a lack
of energy or interest in things, an inability to enjoy normally
pleasurable activities and feelings of helplessness and
hopelessness. On average, someone with bipolar disorder may have
up to three years of normal mood between episodes of mania or
depression.
Bipolar disorder changes the course of your life, but it
doesnt mean you cant do great things, said Holly Swartz, M.D.,
associate professor of psychiatry at the University of
Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic in Pittsburgh (Cornwell, 2010). With a combination of
medication, psychotherapy and self-management strategies,
individuals with bipolar disorder can lead productive,
successful lives. If left untreated, bipolar disorder can wreak
havoc on a persons life. It requires both medical treatment and
psychotherapy. Having a support system is critical in
successfully managing bipolar disorder.
Peplaus (Rust, 2012) theoretical model of the nurse- patient relationship emphasized mutuality as an essential
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13process for an effective nurse-patient working relationship to
foster growth in constructive coping responses toward the goal
of recovery. Mutuality is characterized by both individuals
sharing information and collaborating to make decisions in
relation to jointly agreed-on goals. The concept of mutuality
has been reframed and extended in the concept of shared decision making that involve decision making about therapeutic options.
One of the most common side effects of bipolar disorder is
an intense and inexplicable sense of loneliness. This mental
state causes severe physical and psychological consequences for
people who fail to take adequate precautions or interventions to
avoid ongoing complications.
Loneliness is a universal emotional and psychological
experience. Loneliness is also seen as a normal experience that
leads individual to achieve deeper self-awareness, a time to be
creative, and an opportunity to attain self-fulfilment and to
explore meaning of life. Loneliness is also a condition of human
life, an experience of humanizing which enables the person to
sustain, extend, and deepen his/her humanity. According to Weiss
(2011), loneliness is caused not by being alone but being
without some definite needed relationship or set of
relationships. Loneliness appears always to be a response to the
absence of some particular relational provision, such as
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14deficits in the relational provisions involved in social
support.
Researchers have indicated that adolescents experience more
loneliness than any other age groups. Late adolescence and early
adulthood (i.e., university age) are especially high risk for
experiencing loneliness. Lack of social and emotional support
may lead to the experience of social and emotional loneliness. For the most part, loneliness research has tended to focus on
individual factors, that is, either on personality factors or
lack of social contacts.
The degree, frequency, and quality of a person's loneliness
will be a function, among other things, of the society in which
he or she lives. The UCLA Loneliness Scale is a commonly used measure of loneliness. Its name derives from its having been
developed at the University of California, Los Angeles (UCLA).
It was first published in 1978 by Russell, D., Peplau, L.A., and Ferguson, M.L., and was revised in 1980 and 1996.Developer
Daniel Russell has expressed concern that publication of the
scale could skew responses. The UCLA Loneliness Scale was
developed to assess subjective feelings of loneliness or social
isolation. Items for the original version of the scale were
based on statements used by lonely individuals to describe
feelings of loneliness. The questions were all worded in a
negative or lonely direction, with individuals indicating how
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15often they felt the way described on a four point scale that
ranged from never to often.
Hildegard Peplau (Forchuk,2014) a legendary nurse theorist,
introduced a theory of interpersonal relationships in nursing.
She argued that the purpose of the nurse-client relationship is
to provide effective nursing care leading to health promotion
and maintenance. Within the nurse-client relationship, the nurse adopts one or more of six helping roles when providing care:
stranger, resource person, teacher, leader, surrogate, and
counselor. A seventh role, technical expert, was added later
(Stockman, 2012). Although the seventh role was not included in
Peplaus original theory, all the roles will be referred to as
Peplaus helping roles in this article as is customary in the
nursing literature.
The stranger role occurs when the nurse and the client first meet and become acquainted. They begin the relationship as
strangers, each with preconceived expectations for the first
encounter. The goal of the nurse is to establish the
relationship and build trust with the client. Peplau (Rust, 2012) believed that compassionate verbal and nonverbal
communication, a respectful approach, and nonjudgmental behavior
are essential to this role. Successful implementation of the
stranger role is the foundation for development of a therapeutic
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16relationship and a necessary condition for the establishment of
the other roles.
In the resource person role, the nurse provides specific
factual health information in response to a clients questions
and interprets the clinical plan of care (Rust, 2012). Essential
to this role are expert professional knowledge, the ability to
deliver information in a sensitive manner, and critical thinking
skills needed to process the clients questions and offer a
therapeutic response.
Assisting the client to attain knowledge to improve health
is the primary goal of the teacher role (Forchuk et al., 2013).
This process may be formal, such as providing detailed
instructions for individuals or conducting training sessions for
groups to teach a health-related behavior, or the process may be
informal, such as modeling patterns of health and wellness in
the therapeutic relationship.
The leadership role involves collaboration between the
nurse and the client to meet desired treatment goals. The nurse
offers guidance, direction, and support to promote the clients
active participation in maintaining his or her health. The goal
of the nurse is to help the client accept increased
responsibility for the plan of care (Rust, 2012).
In the surrogate role, the nurse functions as an advocate or a substitute for another human being who is well known to the
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17client, such as a parent, sibling, other relative, friend, or
teacher (Rust, 2012). Through this process a client may
unconsciously transfer behaviors or emotions that are connected
to a significant other onto the nurse. The nurse addresses this
reaction and assists clients to recognize the differences as
well as similarities between themselves and the other.
In the counselor role, the nurse encourages the client to
explore his or her current situation or presenting problem. The
nurse must be aware that such exploration often engenders
anxiety and, therefore, must facilitate an atmosphere that is
conducive for the client to safely express his or her concerns.
To successfully implement the counseling role, the nurse must
demonstrate active listening skills, apply therapeutic
communication techniques, provide guidance and support in the
process of self-discovery, and maintain professional boundaries
and self-awareness (Forchuk et al., 2013)
Although Peplau (Rust, 2012) did not include the technical
expert role in her original work, it is now considered to be one
of the primary helping roles of the nurse-client relationship.
As a technical expert, the nurse demonstrates technical skills
to perform nursing care. The technical expert role includes
physical assessment and interventions and the use of equipment,
such as intravenous pumps, blood pressure cuffs, and
ventilators.
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The implementation of the helping roles (Rust, 2012) has
been described in a number of settings, including psychiatric
and mental health, surgical, and palliative care. Peplau
discusses major features of the theory of interpersonal
relations. She describes her theory as among the most useful to
apply during nursing practice in order to understand nurse-
patient interactive phenomena. Peplau addresses how she derived
constructs from clinical data and identified their congruence
with nursing practice. She further addresses the specific
concepts of her theory and their relations, and specific uses of
the theory in practice.
Peplau went on to form an interpersonal model emphasizing
the need for a partnership between nurse and client as opposed
to the client passively receiving treatment (and the nurse
passively acting out doctor's orders). The essence of Peplau's
theories is the creation of a shared experience thus building
mutuality on both part of the patient and the health provider.
Nurses, she thought, could facilitate this through observation,
description, formulation, interpretation, validation, and
intervention (Fowler, 2011).
Roles of nurse
Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting
climate that builds trust.
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Teacher: who imparts knowledge in reference to a need or interest
Resource Person : one who provides a specific needed
information that aids in the understanding of a problem or
new situation
Counselors : helps to understand and integrate the meaning
of current life circumstances ,provides guidance and
encouragement to make changes
Surrogate: helps to clarify domains of dependence
interdependence and independence and acts on clients behalf
as an advocate.
Leader : helps client assume maximum responsibility for
meeting treatment goals in a mutually satisfying way
Additional Roles include: Technical expert, Consultant, Health teacher, Tutor, Socializing agent, Safety agent,
Manager of environment, Mediator, Administrator, Recorder
observer, Researcher.
Phases of interpersonal relationship (Taylor, 2011)
Identified four sequential phases in the interpersonal
relationship:
1. Orientation
2. Identification
3. Exploitation
4. Resolution
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20I. Orientation phase
Problem defining phase
Starts when client meets nurse as stranger
Defining problem and deciding type of service needed
Client seeks assistance ,conveys needs ,asks questions,
shares preconceptions and expectations of past experiences
Nurse responds, explains roles to client, helps to identify
problems and to use available resources and services
II. Identification phase
Selection of appropriate professional assistance
Patient begins to have a feeling of belonging and a
capability of dealing with the problem which decreases the
feeling of helplessness and hopelessness
III. Exploitation phase
Use of professional assistance for problem solving
alternatives
Advantages of services are used is based on the needs and
interests of the patients
Individual feels as an integral part of the helping
environment
They may make minor requests or attention getting
techniques
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The principles of interview techniques must be used in
order to explore, understand and adequately deal with the
underlying problem
Patient may fluctuates on independence
Nurse must be aware about the various phases of
communication
Nurse aids the patient in exploiting all avenues of help
and progress is made towards the final step
IV. Resolution phase
Termination of professional relationship
The patients needs have already been met by the
collaborative effect of patient and nurse
Now they need to terminate their therapeutic relationship
and dissolve the links between them.
Sometimes may be difficult for both as psychological
dependence persists
Patient drifts away and breaks bond with nurse and
healthier emotional balance is demonstrated and both
becomes mature individuals.
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22Conceptual Framework
Peplau (Rust, 2012) defines man as an organism that
strives in its own way to reduce tension generated by needs.
The client is an individual with a felt need. Healthcare
professionals are considered to be any individuals who provide
services to promote the physical and mental well-being of others
and to care for those who are ill or injured. Peplau (Rust,
2012) described nursing as "a significant, therapeutic, interpersonal process. It functions co-operatively with other
human processes that make health possible for individuals in
communities. Nursing is an educative instrument, a maturing
force, that aims to promote forward movement of personality in
the direction of creative, constructive, productive, personal
and community living". Lack of growth, for whatever reason,
implies impaired health in the individual and basic human needs
must be met if a healthy state is to be achieved and maintained
(Forchuk,2014).
The relationship of nurse and patient is influential in the
outcome for the patient; People may assume a number of roles and
have the capacity for empathy in relationships (Rust, 2012);
People tend to behave in ways which have worked in the past when
faced with a crisis (Forchuk,2014); Anxiety and tension arise
from unmet or conflicting needs, and the energy which arises may
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23be harnessed into positive means for defining, understanding and
meeting the problem at hand.
In 1952, Peplau published her Theory of Interpersonal
Relations that was influenced by Henry Stack Sullivan, Percival
Symonds, Abraham Maslow, and Neal Elgar Miller (Rust, 2012).
Her theory emphasized the nurse-client relationship as the foundation of nursing practice. It gave emphasis on the give-
and-take of nurse-client relationships that was seen by many as
revolutionary. Peplau went on to form an interpersonal model
emphasizing the need for a partnership between nurse and client
as opposed to the client passively receiving treatment and the
nurse passively acting out doctors orders.
The four components of the theory are: person, which is a developing organism that tries to reduce anxiety caused by
needs; environment, which consists of existing forces outside of the person, and put in the context of culture; health, which is a word symbol that implies forward movement of personality
and nursing, which is a significant therapeutic interpersonal process that functions cooperatively with other human process
that make health possible for individuals in communities.
The nurse patient relationship is characterized by a number of overlapping phases with a number of therapeutic tasks or
goals to be accomplished. During each phase the patient
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24expresses needs which find expression and require intervention
in unique ways.
Health is defined as a word symbol that implies forward movement of personality and other ongoing human processes in the
direction of creative, constructive, productive, personal, and
community living (Rust, 2012)
Although Peplau does not directly address society/environment, she does encourage the nurse to consider the patients culture and mores when the patient adjusts to
hospital routine. Hildegard Peplau considers nursing to be a significant, therapeutic, interpersonal process (Rust, 2012).
She defines it as a human relationship between an individual
who is sick, or in need of health services, and a nurse
specially educated to recognize and to respond to the need for
help.
Therapeutic nurse-client relationship. A professional and planned relationship between client and nurse that focuses on
the clients needs, feelings, problems, and ideas.
Nursing involves interaction between two or more
individuals with a common goal. The attainment of this goal, or any goal, is achieved through a series of steps following a
sequential pattern.
The nursing model identifies four sequential phases in the interpersonal relationship: orientation, identification,
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25exploitation, and resolution.
Anxiety was defined as the initial response to a psychic threat.
The phases of the therapeutic nurse-client are highly
comparable to the nursing process making it vastly applicable.
Assessment coincides with the orientation phase; nursing
diagnosis and planning with the identification phase;
implementation as to the exploitation phase; and lastly,
evaluation with the resolution phase.
Four Phases of the therapeutic nurse-patient relationship: 1. The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and
information, and answering questions.
2. The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins
to feel stronger.
3. In the exploitation phase, the client makes full use of the services offered.
4. In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The
relationship ends.
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26Assumption
Nurse and patient can interact. Peplau stresses that
both the patient and nurse mature as the result of the
therapeutic interaction. Communication and interviewing
skills remain fundamental nursing tools. Peplau believed
that nurses must clearly understand themselves to promote
their clients growth and to avoid limiting clients
choices to those that nurses value. It is assumed that the
nurse will utilize Hildegard Peplaus Interpersonal
Relations Theory in the care of the bipolar patient in
response to UCLA (University of California, Los Angeles)
Loneliness Scale,in determining patients level of tendency
towards loneliness. Definition of Terms
Important terms in this study were defined conceptually and
operationally:
Bipolar. Formerly called manic depression, is a mental illness that brings severe high and low moods and changes in sleep,
energy, thinking, and behavior.
Environment. Existing forces outside the organism and in the context of culture
Health. A word symbol that implies forward movement of personality and other ongoing human processes in the direction
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27of creative, constructive, productive, personal and community
living.
Loneliness. A normal experience that leads individual to achieve deeper self-awareness, a time to be creative, and an opportunity
to attain self-fulfilment and to explore meaning of life.
Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that make
health possible for individuals in communities. Person. A developing organism that tries to reduce anxiety caused by needs.
UCLA Loneliness Scale. A commonly used measure of loneliness derives from its having been developed at the University of
California, Los Angeles (UCLA) to assess subjective feelings of
loneliness or social isolation. It was first published in 1978
by Russell, D., Peplau, L.A., and Ferguson, M.L., and was
revised in 1980 and 1996. This 20-item measure has reported high internal consistency and good evidence of construct, concurrent,
and discriminant validity (Hagerty et al., 1996; Russel et al.,
1980). Items were assessed on a four-point Likert scale ranging
from 1 (never) to 4 (always), with a higher score indicating a
greater degree of loneliness. The internal consistency of the
Loneliness scale was 0.86.
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5
Figure 1. Conceptual Framework:
Interpersonal Relations Theory
LowSelfEsteem RESOLUTIONPHASE
PATIENT
SociallyWithdrawnSevereTendency
TowardsLoneliness
EXPLOITATIONPHASE
IDENTIFICATIONPHASE
ORIENTATIONPHASE
NursePatientRelationship
Nurseasa: Stranger Teacher Resource Person Counselor Surrogate Leader
WellRoundedPersonwithRestoredSocialization,
Confidence,SelfIntegrityandEffectiveCopingMechanism.
PATIENT
ASchematicDiagramDepictingtheRelationshipofUtilizingtheEffectivenessofPeplausInterpersonalRelationsTheorypracticingtheNursesTolesthroughoutthephasestowardsthesuccessofpatients
-
Rehabilitation.
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28
CHAPTER III
Application of the Nursing Theory Client Profile
Name: P. U.
Age: 16 years old
Sex: Male
Birthday: July 7, 1998
Address: Esteban Subdivision, Pulupandan, Negros Occ. Civil Status: Child Educational Attainment: 4th year High School Student
Religion: Roman Catholic
History of the Present Illness
The patient had manifest first depression upon returning
home from school one day having ambivalent expression and had his packed lunch untouched. Since then, he consecutively had bouts of sudden crying of getting restless and mad for no apparent reason. He had been skipping classes and found to be with peers who are having recent substance abuse records. He would escape their house at the middle of the night and suddenly resort to being a loner and complain having insomnia.
The patient then had been under the care of Dr. Charibel Escandelor on June 2012. He exacerbated again late last year (2013) and is presently still very symptomatic showing both psychosis band very manic symptoms. His folks have difficulty keeping him at home and ensuring he takes his medicines. He recently had a negative (-) drug test and has no known illness. On March 24, 2014 he had been admitted at the Negros Occidental Drug Rehabilitation Foundation, Inc. and and was discharged June 6, 2014 provided being still on strict medication and a monthly
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29follow up consultation with Dr. Escandelor and the Psychiatrist of the said institution to finish his last year on high school.
Patients Anamnesis
FREUDs ERIKSONs PATIENT ANAMNESIS Once cell differentiation is
mostly complete, the embryo enters the next stage and becomes a fetus. The early body systems and structures established in the embryonic stage continue to develop. The neural tube develops into brain and spinal cord and neurons form. Sex organ begins to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the latter stages of pregnancy.
A. Prenatal
Pregnancy was planned
Mother had pre-natal
Mother is in good
condition Mother has no vices
and is not into drugs No illnesses during
pregnancy
Stage 1. Begins from the onset of true labor lasts until the cervix is completely dilated in 10cm. Stage 2. Continues after the cervix
has dilated to 10cm until the delivery of baby Stage 3. Delivery of the placenta
B. Delivery
The child was born at
The Riverside Hospital, Bacolod City
Normal Delivery
C. Oral Stage
(0-1 year old)
Libido is
Infancy Period
(0-1 year old) Trust V.
Mother is the most significant person
Father is a seaman
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30
focused on the mouth
Individual may be frustrated by having to wait on another person, being dependent on another person,
Mistrust and is absent at times since on board while the child is growing up
Mother is always at the patients side
Patient grew in rural area
He has 5 siblings (2 boys,3 girls) being the 4th child in the family
D. Anal Stage Toddler Period
Autonomy Vs, Shame and Doubt
Patient was toilet trained by mother and sometimes yaya in the toilet
Patient responded positively with the training
Completed immunization
Patient did not experience any physical cruelty
Patient was breastfed until weaned during 2-3 years old while transitioned with bottle-feeding and solid foods during 1
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31
year old E. Phallic Stage
(3-6 years old)
Pre-School Period (3-6 years old) Initiative Vs.
Guilt
Entered the school as a sit in with older brother since 3 years old and started formal schooling the next year
More close relationship to the mother since the father is working abroad
Patient is active at school being a cub scout and always volunteering for roles in every school activities
F. Latent Stage (6-12 years old)
School Age (6-12 years old) Industry Vs.
Inferiority
Being active at school while joining the campus band
Likes to play football and enjoy being with peers
G. Genital Stage (12-18 years old Above)
Adolescence (12-18 years old) Intimacy Vs.
Isolation
Started to try smoking cigarettes
Peer pressures
Became a computer addict
Being hooked with RPG
games, had riot with
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32
co-players and experienced having income solely on bidding game characters and items via net
Cellphone confiscated
once at school because of porn- viewing
Skipping school hours and playing games on computer shops
Always reprimanded being leader of the mischief in class
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33
Summary of Patients Precipitating Factors:
Peer pressure
Insomnia
Low Self-Esteem
Being transferred to private school to be disciplined
Almost always being pressured by the two older brother when there are shortcomings or misbehavior
Strong personality of the mother and quite distant relationship in contrast to earlier version of maternal image
No outlet at home nor in friends
Stress in school transition and academy workloads
Reports being bullied at school
Addiction in computer began Health History
A. History of Present Illness
The patient then had been under the care of Dr.
Charibel Escandelor on June 2012. He exacerbated again late last year (2013) and is presently still very symptomatic showing both psychosis band very manic symptoms. His folks have difficulty keeping him at home and ensuring he takes his medicines. He recently had a negative (-) drug test and has no known illness. On March 24, 2014 he had been admitted at the Negros Occidental Drug Rehabilitation Foundation, Inc. and and was discharged June 6, 2014 provided being still on strict medication and a monthly follow up
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34
consultation with Dr. Escandelor and the Psychiatrist of the said institution to finish his last year on high school.
B. Past Health History a. Childhood Illness
The patient had no known childhood illness. b. Past Hospitalization
The patient had once been admitted at The
Doctors Hospital on 2010 due to Dengue. c. Serious Illness/Chronic Illness
So far the most serious illness that had
been diagnosed with the patient is having a bipolar disorder diagnosed during 2012 which he had been managed with medication to the present while having monthly and now, adjusted to every 3 months visit to the Psychiatrist. d. Previous Surgery
The patient had only done circumcision procedure
during earlier years and no previous surgery done. C. Family History
Both sides of the family had one or two distant relatives having nervous breakdown.
D. MSE PROPER
1. General Appearance
The patient is well-groomed and sometimes being too conscious of appearance. He likes to wear fit but comfortable clothes and presently argue to resist haircut that is too long for a school prescribed haircut.
2. Characteristic of Speech
The patient talks in a well-modulated voice, speaks spontaneously and can express self. Patient
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35
sometimes stutters and stammers in prolonged conversation and fast-paced discussions
3. Mood and Affect
Patients is always on ambivalent expression except when watching favorite anime that transforms him also into being animate and charged with motivation and positive disposition.
4. Form of Thought
The patient has a history of auditory hallucinations esp. during the time of insomnia at the first phase of his emerging symptoms. He also have illusions once being a part of a powerful force and the delusion of grandeur being a special being, all-knowing and all-seeing creature.
5. Sensorium Function
ORIENTATION
10 Khans Questions(When he was still admitted):
a. What is the name of this institution?
>> Rehab.
b. Where is it located?
>> Victorias.
c. What day of the week is today?
>> My day.. judgment day.
d. What is the month now?
>> March eh!
e. What is the year now?
>> 2014..
f. How old are you?
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36
>> 15 kabos la ko ka intra the Voice
Audition
g. When were you born?
>> July 7, 1998
h. Where were you born?
>> Hospital sa Bacolod.
i. Who is the president now?
>> ..si P-noy ah.
j. Who is the president before?
>> :.. si Gloria. GMA
Evaluation:
The patient is oriented to person,time, place and situational orientation, though he had answered sarcastically the day of the week. Patient answered 9 out of 10 Khans question correctly, thus patient has mild brain organic syndrome. He had a sense regarding of his surroundings and congruence of his response.
Prognosis
Factors Good Poor
I. Onset of Illness
A. Early 20 and above 40
B. Between 20 and 40
II. Education Attainment
A. Highschool
B. College
III. Sex
A. Male
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37
B. Female IV. History of Present Illness
A. Familial
B. None
V. History of Admission
A. Chronic
B. Acute
VI. Socio-Economic Status
A. Poor
B. Rich
VII. Family Support
A. With Family Support
B. Without Family Support
VIII. Pre- Morbid
Personality A. Introvert B. Extrovert C. Ambivert
IX. Compliance to Medication
A. With Compliance
B. Without Compliance
Evaluation:
Patient overall has a good prognosis of his current
condition since the result of the evaluation shows 5 out of 9. Having 4 negative or bad outcomes that can be wired easily in patients good compliance to medication and treatment regimen so there will be no exacerbation symptoms.
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38
Nurse-Patient Interaction (NPI) Nurse-Patient Interaction (NPI)Day 1 11/24/2014
Nurse Interaction
Patient Interaction
Nurse Inference Patient Inference
Sir good morning, ako gali imo nurse subong.
Good morning man
Giving information To have formal
introduction to the patient
Smiles and responds well
Kamusta man matyag mo subong sir?
Ok lang. Encouraging description To let him express
his emotions on that certain time
Smiles and focuses more on the interaction.
Ano sir ang rason ngaa na rehab ka man?
Nag padungol abi mo. Tak an sila sakun pasaway dan.
Exploring To know if he is
open and knows the reason of his admission to the institution
Looks shyly and slightly withdrawn
Ano nga padungol na sir?
Ga mauy ko bi.. ga panigarilyo kag kis a tilaw2 man..
Focusing Concentrating on a
single point
Slightly hesitant to confide some information
Ano man na ang natilawan nyo sir?
Marijuana pero kis-a lang to ya. Sigarilyo pa gid kag pahubog e.
Probing Persistent
questioning of the client
Open gesture and lightly respond to the question
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39
Nurse-Patient Interaction (NPI)Day 2 11/25/2014 Nurse
Interaction Patient
InteractionNurse Inference Patient
InferenceGood morning sir!Daw busy subong sir aw..
indi gid man a. na testingan ko lang liwat himu pispis
Broad Opening Allowing the
client to take initiative in introducing the topic
Encouraging description To understand
what he is doing
Busy doing something but openly respond when approached
Ano na siya nahimo mo sir? Daw ga concentrate ka gid aw?
Ahh activity ni namon kagina pi-ud2x papel origami.
Open gesture and demonstrate paper origami making of a bird
Baw.. kasagad gali sa imo sir bha..
Indi mangid a.
Giving recognition To give
acknowledgement and appreciation
Smiling Happy
Nag enjoy ka gid gali ka gina sa activity nyo sir?
Huo. Indi gid man gali budlay.
Encouraging expression To let him
express emotions
Smiling and enjoying what he is doing
Te anhon mo na dayun sir?
I-display ni kuno namon sa table didto karun huh, pa nami2 a.
Formulating a plan of action Asking the
client to consider what plans he is considering
Shows enthusiasm
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40
Nurse-Patient Interaction (NPI)Day 3 11/26/2014 Nurse Interaction
Patient Interaction
Nurse Inference Patient Inference
Good morning sir. Updan ta lang ka di anay sir subong a.
Pwede gid a.
Offering Self Making oneself
available
Open gesture; Responds well
Silence Encourage him to
express feelings while proving him time to organize thoughts
Remains calm but quite distant
Kadalum gid sang napanumdom ta sir aw?
(smiles gently).. wala gid man a.
Encouraging expression To let him express
emotions
Somewhat hesitant
Basi may gusto ka ishare sir..
(smiles) Suggesting collaboration To let the patient
open up and identify problems while growing emotionally with others.
Still distant
Sige sir a.. indi ka pa guro ready mag open up sharing..
Dason lang nurse a.
Translating into feelings Voicing what the
patient has hinted
Smiles and attentive
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41
Nurse-Patient Interaction (NPI)Day 4 11/27/2014 Nurse Interaction
Patient Interaction
Nurse Inference Patient Inference
Hi sir. Nagkwa ka gali test bag o lang.
Huo. Pa kwa ko nila Ms. Daphne
Broad Opening Allowing the
patient to take initiative in introducing the topic
Responds well
Te kamusta ang test sir?
Hapos lang man a. Damu galing answeran. Kapoy.
Encouraging description of perceptions Asking client to
verbalize what he perceives
Opens with the topic
Daw parehas lang nagkwa ka exam sa skwelahan gali.
Kapoy e. ga liguy gani.. hehe
Encourage Comparison Asking that
similarities anddifferences benoted
Answers mischievously
Abaw, storyahi ko na bi sang liguy mo sir?
Kis-a e. mga barkada ko na classmate hagaray di magsulod kag bakasyon sa computeran. Sadja daw Haha
General Leads Giving
encouragement to let him continue the topic
Reminiscing happily
Te sir, ano man nabatyag nyo after naman gali ya ka computer session nyo nag cut kamo classes?
Sadya gid eh. Ako dan ang leader galling na konsensiya man ko mag abot sa balay.
Reflecting Directing thoughts
and feelings back to him
Somewhat guilty but still radiates from the memory
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42
Nurse-Patient Interaction (NPI)Day 5 11/28/2014 Nurse Interaction
Patient Interaction
Nurse Inference Patient Inference
Daw kasubo sa aton sir aw?
Bag o lang di halin bi mga bisita ko. Daw nasubo an man ta pag bye2x nila bha..
Making Observations Verbalizing what
the nurse perceives
Openly responds
Nahidlaw ka gid sa ila siguro?
Oo. Consensual Validation Searching for
mutual understanding
Falls silence
Nahidlaw ka gid sa ila sir aw?
Kasadja kung ara sila pero mabatyagan ko naman nga kulang kung wala naman sila.
Restating Repeating the main
idea expressed
Responds solemnly
Storyahe ko bi sir panu mo ma describe ang ka kulang na nabatyagan mo?
Daw ka amo na e. kulang. Subo ka naman. Tapos na ang party.
Exploring Delving further
into the subject
Opens up
So, na mean mo sir daw ka temporary lang ang kalipay nyu na mabatyagan. Maumpawan kamo if ara friend nyo pero gakadula man maglakat na sila?
Siguro.. daw ka ako na lang dayun bi isa.
Summarizing Organizing and
summing up what have he had expressed.
Reflects deeply
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43Assessment Tool
Methodology
An adapted questionnaire the UCLA Loneliness Scale is used
as a measure of loneliness. Its name derives from its having been developed at the University of California, Los Angeles (UCLA). It was first published in 1978 by Russell, D., Peplau, L.A., and Ferguson, M.L., and was revised in 1980 and 1996. The internal consistency of the scale was high and the reported correlations with measures of emotional loneliness, social loneliness, self-esteem, depression, and personality traits, supported the convergent and discriminant validity of the scale.
The scale consists of 20 items (11 positive and 9
negative), describing subjective feelings of loneliness, none of which refers specifically to loneliness. A 20-item scale designed to measure ones subjective feelings of loneliness as well as feelings of social isolation. Participants rate each item as either O (I often feel this way), S (I sometimes feel
this way), R (I rarely feel this way), N (I never feel this way). The 20 items are rated on a 4- point Likert scale in accordance with the rate of frequency, the following corresponding weights were assigned to every response. Scores on the scale range from 20 to 80 with higher scores reflecting greater loneliness.
Using data from prior studies of college students, nurses, teachers, and the elderly, analyses of the reliability, validity, and factor structure of this new version of the UCLA Loneliness Scale were conducted. Results indicated that the measure was highly reliable, both in terms of internal consistency (coefficient alpha ranging from .89 to .94) and test-retest reliability over a 1-year period (r = .73).
-
44Convergent validity for the scale was indicated by significant correlations with other measures of loneliness. Construct validity was supported by significant relations with measures of the adequacy of the individual's interpersonal relationships, and by correlations between loneliness and measures of health
and well-being. Confirmatory factor analyses indicated that a model incorporating a global bipolar loneliness factor along with two method factor reflecting direction of item wording provided a very good fit to the data across samples.
The nurse utilized this tool by allowing the patient to answer the questionnaire that best describes his responses. The response will be tallied, computed, analyzed and interpreted. The assessment tool was translated verbally according to patients dialect in order to understand the items asked and give accurate response.
Computation of Clients Score
The data treatment is at the ordinal level, where the MEAN
score of the client per category was computed and ranked to determine the priority of the problem and the overall mean to indicate the level of patients loneliness as the basis of treatment to be applied throughout the entire Nurse Patient Relationship in utilization of Peplaus Theory.
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45
Formula for Mean
The mean is obtained by dividing the summation of scores in
all the questions in the assessment tool.
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46
Table1.Initial Assessment Score Scale
Value
(initialassessment phase) (final assessmentphase)
SummationofFrequencyineachScale
MEANUCLAScore
SummationofFrequencyineachScaleB
MEANUCLAScore
1 Never 0 071
2 Rarely 0 0 3 Sometimes 11 0.55 3.55 4 Always 9 0.45
Total/OverallAverageMeanScore
20 1 80
0.89
UCLA Scoring:
21-30: People within this range would indicate manageable
instances of loneliness and effective coping up.
31-40: People attaining this score-range are operating comfortably and experience an average level of loneliness.
41-60: People within this range struggle a little with social
interactions, experiencing frequent loneliness.
61-80: Scores falling within this range would indicate a person experiencing severe loneliness.
Scale of Means Description
4 (61-80) Relatively Severe Tendency to Loneliness
3 (41-60) Relatively High Tendency to Loneliness
2 (21-40) Relatively Average Tendency to Loneliness
1 (1-20) Incompletely Answered Questionnaire
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47Interpretation of the Score
Scale of Means Description
3.05 4.00 Relatively Severe Tendency to Loneliness
2.05 - 3.00 Relatively High Tendency to Loneliness
1.05 2.00 Relatively Average Tendency to Loneliness
0.00 1.00 Incompletely Answered Questionnaire
Relatively
Average Tendency to Loneliness
Relatively Severe
Tendencyto Loneliness
Incompletely Answered
Questionnaire
Relatively High Tendency to Loneliness
1 2 3 4
Figure 2. Evaluative Scale Utilized
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Figure 3. Evaluative Scale of Mean During Initial 47Assessment
Relatively Severe Tendency to Loneliness
1 2 3 4
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48PlanningPhase
Table2.NursingCarePlan
ASSESSMENT NURSING
DIAGNOSISOBJECTIVESOFCARE
SubjectiveData:
Nasubuannakodi..
Indikokisamayokatuloggid.
Walapasilakabisitasaakon
bi.
Kadugaypakomakapuliguruni.Takannakodi.
Suboe.Ladaankalingawan
gid.
ObjectiveData Lackofgoaldirectedbehavior Useofformsofcopingthat
impedeadaptivebehavior(includinginappropriateuseofdefensemechanisms,verbalmanipulation)
Inabilitytomeetroleexpectation(noexercise,poorconcentration)
Behavioralchanges: Impatience Frustration Irritability Discouragement
IneffectiveCopingrelatedtodepressionandfeelingsofhopelessnessasevidencedbyverbalizationofloneliness,decreaseduseofsocialsupport,poorconcentration,impatience,irritability,insomnia,lackofenergy,nonparticipationattimes,lowselfesteemandascoreof71inUCLAwhichindicateapersonexperiencingsevereloneliness
Within14daysofnursinginterventionatNEGROSOCCIDENTALDRUGREHABILITATIONCENTERthepatientwillbeableto:
1. Improveorincreasecollaborationwiththerehabilitationnurse/staff.
2. Assesscopingabilitiesandskills.3. Assistclienttodealwithcurrent
situation:a. Encouragecommunicationwith
staff/S.O.b. Providecontinuityofcarewith
thesamepersonneltakingcareoftheclientasoftenaspossible.
c.Scheduleactivitiessoperiodsofrestalternatewithnursingcarewhileincreasingactivitiesslowly.
d. Assessclientinuseofdiversion,recreation,relaxationtechniques.
e. Encourageclienttotrynewcopingbehaviorswhileconfrontwhenbehaviorisinappropriate,pointingoutdifferencebetweenwordsandactionswhileprovidingexternallocusofcontrol,enhancingsafety.
4. Providemeetingpsychologicalneeds.
5. Promotewellness.a. Provideandencouragean
atmosphereofrealistichope.b. Giveinformationandsideeffects
ofmedications/treatments.c.Discusswaystodealwith
identifiedstressors.
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49
Table3.MonitoringChart
NursingIntervention/Rationale
ImplementationDays Evaluation/Outcomes1 2 3 4 5 6 7 8 9 1
011
12
13
14
Independent:
1.VisitMr.PUin
NEGROSOCCIDENTALDRUGREHABILITATIONCENTER.Discussthepurposeofthestudyandinterviewwillbeconducted.EstablishrapportwithMr.Pu.[Establishingrapportwillincreasepatientparticipationandeaseindategathering.]
2.Gatherpertinentdata
aboutMr.PUfromtheNODRCrecordsandstaff.[Baselinedatawillserveasthebasisforcomparisonofanysignificantchangesoralteration.]
3.ObserveMr.PUsself
managementtowardshisillnessortowardsthesignsandsymptomsofthedisease(Bipolar).[Observationofhisreactiontowardsillnesswillprovidesignificantdataandconcreteconfirmationofhislonelinessassessment.
After14days of continuousnursingintervention,effectiveillnessmanagementofthepatientwasattainedasevidencedby:
1. Increasecollaboration
withhealthcareproviders.
2. Participateinhisplanofcare.
3. Exhibitselfesteemandmotivation.
4. Continuoustakeshismedicationwhiledemonstratingimprovementinrehabilitation.
5. Alleviatesenseofdespair,socialisolationandloneliness.
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50
4.DetermineMr.PUshealthbeliefs,patternsofcopingwithillnessandattitudetowardsrehabilitation.[DeterminingMr.PUshealthbeliefpattern,selfawareness,andperspectiveofhisconditiontohaveaconcreteunderstandingofthesubjectivedatagathered.]
5. InitiateNursePatient
Interaction (NPI)withMr.PU.[Providecareforclientsinneedofpsychosocialintervention.]
6. Provideasafe
environmentfortheclient.[Physicalsafetyoftheclientisapriority.]
7. Allowclientto
expressopinions,perceptions,emotionsinappropriateandsafemannerwhileprovidingprivacyifhedesiresanditissafetodoso.[Clientmaynotfeelcomfortableinexpressingfeelingsandmayneedencouragement
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51
orprivacy.
8. Encourageclienttoventilatefeelingsinwhateverwayiscomfortableverbalandnonverbal.Lettheclientknowyouwilllistenandacceptwhatisbeingexpressed.[Expressingfeelingsmayhelprelievedespair,hopelessnessandsoforth.Feelingsarenotinherentlygoodorbad.Youmustremainnonjudgmentalabouttheclientsfeelingsandexpressthistotheclient.]
9. Teachtheclient
aboutproblemsolvingprocess:explorepossibleoptionsexaminetheconsequences,ofeachalternative,selectandimplementanalternative,andevaluatetheresult.[Theclientmaybeawareofasystematicmethodforsolvingproblems.Successfuluseof
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52
problemsolvingprocessfacilitatestheclientsconfidenceintheuseofcopingskills.]
10.Providepositive
feedbackateachstepoftheprocess.Iftheclientisnotsatisfiedwiththechosenalternative,assisttheclienttoselectanotheralternative.[Positivefeedbackateachstepwillgivetheclientmanyopportunitiesforsuccess.Encouragehimtopersistinproblemsolving,andenhanceconfidence.Theclientcanalsolearntosurvivemakingamistake.
DependentNursingAction:
11.Monitorintakeof
dailymedication(Olanzapine,Haloperidol,Valpros)[Assuresadherencetomedication.Observanceof10rightsofgivingmedication
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53
shouldbefollowed.]
CollaborativeNursingAction:
12.Collaboratewith
theRehabilitationnurseintheprovisionofdailymedication.[Continuumofcare.]
13.Review
endorsementprocedureandreferralprocessesfollowedinNODRC
14.Coordinatewiththepsychiatrist,Administrator,nurseandauthorizedpersonsregardingeveryinteractionandresultsorprogresswiththeinterventiontakenon theclient.
15.Assistinpatients
takingofassessmenttoolsandfollowupresultstobeutilizedasatoolindeterminingnursepatientinteractionandintervention.
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54ImplementationPhase
TheprogressofMr.PUonhiscopinguppatternsweremonitoredandrecordedforaperiodof
14daysfromNovember24,2014toDecember7,2014.Reflectedonthetablebelowarethechangesofhisbehavioralpatternwhilethenursinginterventionswereimplementedthroughoutthe14dayperiod.
NursingDiagnosis
Day1(November24,2014)
Day 2(November25,2014)
Day 3(November26,2014)
Day4(November27,2014)
Day 5(November28,2014)
IneffectiveCopingrelatedtodepressionandfeelingsofhopelessnessasevidencedbyverbalizationofloneliness,decreaseduseofsocialsupport,poorconcentration,impatience,irritability,insomnia,lackofenergy,nonparticipationattimes,lowselfesteemandascoreof45inUCLAwhichindicateapersonexperiencingsevereloneliness
Difficultyinsocializingwithothersnoted.
Looks shyly and slightly withdrawn.
Slightly hesitant to confide some informatio n.
UCLA Loneliness Scale Questionna ire had been answered
Busy doing something but openly respond when approached.
Quitehesitantbutwilling toparticipate indiscussion.
Remains calm but quite distant
Somewhathesitant
Slightlydriftinginthoughts
PatienttakestheDuilfordZimmermanTemperamentSurveyintherehabilitation. Quitereflective Sharesabitofremorse. Reminiscence.
Patient hasbeen visitedbyfriends.RespondssolemnlyindeepreflectionUnattentiveExpressfeelingsoflonelinessandmissingacozyatmosphere.
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55Day6(November29,2014)
Day7(November30,2014)
Day 8(December1,2014)
Day 9(December2,2014)
Day 10(December3,2014)
Presentintheactivitybutdoesnotparticipate. Lowenergy Quitedistantandindeepthoughts Politebutstillpreferstobeundisturbed. Privacygiven.
Attended
communion. Participativeand
listensintentlyonthehomily.
Nurseandpatientinteractionconducted.
Expressedfeelingsofdespairandloneliness.
Delveddeeperintocauseofloneliness.
Patientexpressedmissingpastactivitiesandhobbies.
Patientreflectsrootofloneliness
Patientisambivalent.
Joinedintheactivitybutlacksenthusiasm
Patientconversewithotherpatientsbriefly.
Patientishesitantatfirstininteractingwiththeactivities.Patientisbeingwatchfulwiththemechanicsofthegame.Encouragetotakepartinthegameandcheeredonbybothstaffandfellowpatients.Patientexpressedtirednessbutinopenexpression.
Day11(December4,2014)
Day12(December5,2014)
Day 13(December6,2014)
Day14(December7,2014)
Patientisnostalgicafterviewingfavoritecartoons.Patientisbeingattentiveindiscussionaboutthecartoons.Possiblecopinguphasbeenestablishedespeciallyinmotivatingthepatientforplanningtowhatcoursehewilltakeforcollege.
Patienthasplayed
soccerafterschool. Patienteatsdinner
andquitetiresome,takehismedicines,restforabitwhilewatchinghisfavoriteshowandfinallygettosleep.
Patientsrelativesarrived.
Patientinteractedinthe living roomwiththefamily.
Attendedthe
HolyMass. Patient
interactedwithsomefriends.
AnsweredtheUCLALonelinessScaleagain.
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56
Table4.FinalAssessmentScore(finalassessmentphase)
MeanDifferenceSummationofFrequencyineachScaleB
MEANUCLAScore
4 0.2045
0.209 0.45 0.455 0.25 2.25 0.302 0.10 0.35
20
1 80
0.56
1.30
Table5.MeanDifferencebetweentheInitialandFinalAssessment
Scale
Value
(initialassessment phase) (final assessment phase) MeanDifference
SummationofFrequencyineachScale
MEANUCLAScore
SummationofFrequencyineachScaleB
MEAN UCLAScore
1 Never 0 071
4 0.20 45
0.202 Rarely 0 0 9 0.45 0.453 Sometimes 11 0.55 3.55 5 0.25 2.25 0.304 Always 9 0.45 2 0.10 0.35
Total/OverallAverageMeanScore
20 1 80
0.8920 1
800.56
1.30
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57
Figure4.ComparativeLevelofLonelinessTendencyBetweentheInitialandFinalAssessmentResultofMr.PU
1 2 3 4
1.30
Figure5.ComparativeLevelofInitialandFinalAssessmentinChart
12 60.00%
10 50.00%
8 40.00%
6 30.00%
4 20.00%
2 10.00%
0SometimesAlways Value Never RarelySometimesAlways
3 4 Role 1 2 3 4
0.00%
Count Percent
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58Evaluation Phase
The clients mean difference was extracted by subtracting
Mr. PUs initial assessment results of overall means from the initial assessment results. Overall mean of 1.30 was observed implying a significant improvement in clients tendency to loneliness.
Findings
The overall mean score Mr. PU in the initial assessment is
3.55 that shows his relatively high tendency to loneliness. After 14 days of nurse-patient interaction and provision of nursing intervention, the clients overall mean score in the final assessment decreased to 2.25. The mean difference from the initial mean score is 1.30. This shows that there is improvement from the clients tendency to severe loneliness to be relatively tolerable while he keeps warding off from his loneliness tendency.
Conclusion:
Through the statistical findings presented, it can be
concluded that by recognizing tendencies to loneliness of the client is an essential assessment tool to be utilized in Peplaus Nurse-Patient Interaction to further assist the patient in his needs and to understanding condition thatcan be the key to patients trust and further assistance to the restoration of self-integrity and promotion of health. The 14 day trial is just a short course and if the clients score keeps on improving in moderating his inclination towards loneliness, self-esteem, confidence, trust in others and successful rehabilitation would be inversely attain.
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Recommendation:
The utilization of UCLA Loneliness Scale Assessment tool in resonance to Peplaus Interpersonal Relationship Theory as a concrete measurement in determining the loneliness and the gravity of emotional need and psychological support of the patient is highly recommended. It is essential not only to the psychologically challenged but also applicable to different kinds of patients with regards to emotional stability of a person.
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References: Bailey, Alan. The effectiveness of Motivational
Interviewing for Young People Engaging in Problematic
Substance Use. 2012.
http://www.headspace.org.au/media/326688/motivational_
interviewing_for_young_people_engaging_in_problematic_
substance_use_headspace
Cacioppo JT, et al. Loneliness within a nomological net: An
evolutionary perspective. Journal of Research in
Personality. 2013;40(6):10541085. Retrieved from
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Cornwell EY, Waite LJ. Social disconnectedness, perceived
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Dussault, Marc, and ric Frenette. "Loneliness and Bullying
in the Workplace." American Journal of Applied
Psychology 2, no. 4 (2014): 94-98.
Forchuk C. The orientation phase of the nurse-client
relationship. Testing Peplaus theory. Journal of
Advanced Nursing. 2014:4;20:532537. [PubMed]
Forchuk C, et. al. From hospital to community: Bridging
therapeutic relationships. Journal of Psychiatric and
Mental Health Nursing. 2013;5:197202. [PubMed]
Fowler J. Taking theory into practice: Using Peplaus model
in the care of a patient. Professional Nurse.
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2011;10:226230. [PubMed]
Gastmans C. Interpersonal relations in nursing: A
philosophical-ethical analysis of the work of
Hildegard E. Peplau. Journal of Advanced Nursing.
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Howk, C (2012). Hildegard E. Peplau: Psychodynamic Nursing.
In A. Tomey & M. Alligood. Nursing Theorists and their
Work (7th ed., pp. 338). St. Louis, Mosby. Retrieved
from: http://en.wikipedia.org/wiki/Hildegard_Peplau
Lego S. The application of Peplaus theory to group
psychotherapy. Journal of Psychiatric and Mental
Health Nursing. 1998;5:193196. [PubMed]
National Institute on Drug Abuse. High school and youth
trends. 2011 Available at
http://drugabuse.gov/pdf/infofacts/HSYouthTrends.pdf.
Peplau, H.E. (1954). Utilizing themes in nursing
situations. American Journal of Nursing, 54, 325328.
doi:10.2307/3460657 [CrossRef]
Russell DW. UCLA Loneliness Scale (Version 3): Reliability,
validity, and factor structure. Journal of Personality
Assessment. 1996;66(1):2040. [PubMed]
Staff, Casa Palmera .Drug Abuse and Depression in Teens.
2010, Posted on Tuesday, January 5th, at 3:37 am.
Retrieved from http://casapalmera.com/drug-abuse-and-
depression-in-teens/
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Stockburger , Jillian. Force on Substance Abuse Youth
Voices on the Prevention and Intervention of Youth
Substance Abuse. 2014. Retrieved from
http://www.unbc.ca/assets/centreca/english/piysa.pdf
Stockman C. A literature review of the progress of the
psychiatric nurse-patient relationship as described by
Peplau. Issues in Mental Health Nursing. 2012;26:911
919. [PubMed]
Stuart, G.W. & Sundeen, S.J. (1987). Principles and
Practice of Psychiatric Nursing (3rd Ed). St. Louis,
USA: C.V. Mosby Co. Retrieved from
Substance Abuse and Mental Health Services Administration.
(2004). National consensus statement on mental health
recovery. Retrieved from
http://download.ncadi.samhsa.gov/ken/pdf/SMA05-
4129/trifold.pdf.
Substance Abuse and Mental Health Services Administration.
(2013). SAMHSAs shared decision-making (SDM): Making
recovery real in mental health care project. Retrieved
from
http://download.ncadi.samhsa.gov/ken/msword/SDM_fact_s
heet_7-23-2013.doc.
Taylor Carol, (2011). The Art & Science Of Nursing Care 4th
ed. Philadelphia, Lippincott.
Torres, G. (2012). Theoretical Foundations of Nursing. USA:
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Appleton-Century-Crofts.
Zhou, S. X. (2012). Gratifications, loneliness, leisure
boredom and self-esteem as predictors of SNS-game
addiction and usage pattern among Chinese college
students. International Journal of Cyber Behavior,
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international.org
Weiss BM, Williams AR. The effects of sense of belonging,
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[PubMed]
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LettertoConducttheStudyNovember24,2014Dr.ErnestoA.PalancaNegrosOccidentalDrugRehabilitationFoundation,Inc.CampGenAnicetoLacsonCompound,VictoriasCity,NegrosOccidentalDearSir,Theundersigned,apostgraduatestudentofNorthernNegrosStateCollegeofScienceandTechnology,iscurrentlyundertakingastudyofthepatientwithBipolarDiagnosis. Inconnectionwiththeabovestatement,Iwouldliketorequestapermissionfromyourgoodofficetoallowmetoconductastudyononeofyourpatient.Yourpositiveresponseonthismatterishighlyappreciated.MorepowerandGodbless!RespectfullyYours,TIFFANYALTEZAC.UNTAL,RNMNSTUDENT,NONESCOSTNoted:Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.D
CLINICALPAPERADVISER
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LettertoConducttheStudy
November24,2014MS.JUVYA.PEPELLONegrosOccidentalDrugRehabilitationFoundation,Inc.CampGenAnicetoLacsonCompound,VictoriasCity,NegrosOccidentalDearMaam,Theundersigned,apostgraduatestudentofNorthernNegrosStateCollegeofScienceandTechnology,iscurrentlyundertakingastudyofthepatientwithBipolarDiagnosis. Inconnectionwiththeabovestatement,Iwouldliketorequestapermissionfromyourgoodofficetoallowmetoconductastudyononeofyourpatient.Yourpositiveresponseonthismatterishighlyappreciated.MorepowerandGodbless!RespectfullyYours,TIFFANYALTEZAC.UNTAL,RNMNSTUDENT,NONESCOSTNoted:Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.D
CLINICALPAPERADVISER
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66
LettertothePatient
November24,2014Mr.P.U.DearSir,Theundersigned,apostgraduatestudentofNorthernNegrosStateCollegeofScienceandTechnology,iscurrentlyundertakingastudyofthepatientwithBipolarDiagnosis. Inconnectionwiththeabovestatement,Iamhumblyaskingyourpermissiontoallowmetoconductastudyyourcase.Yourpositiveresponseonthismatterishighlyappreciated.Itwouldbeagreatprivilegeifyoucouldshedlightonthismatter.MorepowerandGodbless!RespectfullyYours,TIFFANYALTEZAC.UNTAL,RNMNSTUDENT,NONESCOSTNoted:Atty. JOSEPH GEDEONI C. VALENCIA RN, MN, Ph.D
CLINICALPAPERADVISER
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Appendix B
Assessment Tool NEGROS OCCIDENTAL DRUG REHABILITATION CENTER
Managed by: NEGROS OCCIDENTAL DRUG REHABILITATION FOUNDATION, INC.
Camp Gen. AnicetoLacson Compound, Victorias City, Neg. Occ.
PSYCHOLOGICALASSESSMENTGUILFORDZIMMERMANTEMPERAMENTSURVEY
I.PATIENTINFORMATIONPatient:P.U.Age:16y.o.Sex:MII.TESTRESULTS
G R A S E O F T P MRS 22 15 17 16 20 10 9 14 16 13% 55 10 20 10 30 5 15 15 35 10 AA VLA BA VLA BA VLA BA BA BA VLA
III.TESTINTERPRETATION Resultsshowthatthepatientdisplaysahighly impulsivebehavior.Hetendstoactonthefirstthoughtthatcomes intohismind,withoutthinkingaboutthepossibleconsequenceshisactionsmightbring.Asaresultofthisbehavior,hehasthetendencytogethimselfintroublemostofthetime.Itisalsoshownthathisenergylevelishighercomparedtomostpeopleofhisageandsex.Thiswouldmeanthathewouldenjoydoingactivitiesatsuchafastpace,ashedoesnotgettiredquickly.Hemaygetthingsdoneasfastaspossible.Theremightbetimeswherehewouldgetrestlessaswell. In termsofsociability, thepatientshowssignsof introversion.He ismost likely tostay in thebackgroundwhenattendingsocialevents.Heseemstobesociallywithdrawn.Hewouldusuallyisolatehimselffromcrowds,asheprefersspendingtimealone.Hedoesnotseemtomindhavingonlyafew
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68
friendswithhim.Apartfromhisintroversion,heisalsoshowntobetoosubmissive,meaningheislikelytheonetofollowratherthantolead.Heisinclinedtofollowwhateverheisbeingtoldtodo,evenifhefeels thathe cannothandle the responsibility given tohim. It is also indicated thathehas ahostilepersonality. Because of this, peoplemight find it hard to get alongwith him.He tends to have anaggressivesidewhichwouldcomeoutwhensomeonewouldprovokehim.Also,heseemstobefondofbelittlingandmockingothers.Wheneveronecommitsamistake,heislikelytomakefunofthatindividualwithoutbeingconsiderateofhis/herfeelings. Resultsalsoindicatethatthepatientmaybesufferingfromapossiblemooddisorder.Hisfeelingstendtoshift fromtimetotime,withoutanyreason.Heseemstobequitenegativewhen itcomestohimself.Hemayfeelinsecuremostofthetime,especiallywhenbeingwatchedandcriticizedbyothers.Hedoesnotappeartotakeconstructivecriticismslightlyandwouldgetaffectedeasily.Also,hetendstobeemotionallyexpressive.Hehasnodifficultywithshowinghisfeelingstoothers.Lastly,itisshownthathemayhaveparanoiatendencies.Heisusuallysuspiciousofthosearoundhim,andhemayfindithardtotrustpeopleeasily. Preparedby: Approvedby:DaphneElyseKeng Ms.JuvyPepelloJuniorPsychologist Administrator
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Appendix B Assessment Tool
UCLA LONELINESS SCALE INSTRUCTIONS: Indicate how often each of the statements below is descriptive of you.
4 indicates I often feel this way 3 indicates I sometimes feel this way 2 indicates I rarely feel this way 1 indicates I never feel this way
1. I am unhappy doing so many things alone 4 3 2 1 2. I have nobody to talk to 4 3 2 1 3. I cannot tolerate being so alone 4 3 2 1 4. I lack companionship 4 3 2 1 5. I feel as if nobody really understands me 4 3 2 1 6. I find myself waiting for people to call or write 4 3 2 1 7. There is no one I can turn to 4 3 2 1 8. I am no longer close to anyone 4 3 2 1 9. My interests and ideas are not shared by those around me 4 3 2 1 10. I feel left out 4 3 2 1 11. I feel completely alone 4 3 2 1 12. I am unable to reach out and communicate with those around me 4 3 2 1 13. My social relationships are superficial 4 3 2 1 14. I feel starved for company 4 3 2 1 15. No one really knows me well 4 3 2 1 16. I feel isolated from others 4 3 2 1 17. I am unhappy being so withdrawn 4 3 2 1 18. It is difficult for me to make friends 4 3 2 1 19. I feel shut out and excluded by others 4 3 2 1 20. People are around me but not with me 4 3 2 1 Scoring: Items 1, 5, 6, 9, 10, 15, 16, 19, 20 are all reverse scored. Keep scoring continuous.
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N C P |1
AppendixCNursingCarePlans
NURSINGCAREPLAN#1
ASSESSMENT NURSINGDIAGNOSIS
RATIONALE DESIREDOUTCOME
NURSINGINTERVENTION
JUSTIFICATION EVALUATION
ActualCues
Subjective:Thepatientverbalized,Kisindikokabalopanuihambalnameankonamaintindihangidnila.Natayugannasilakuno.WalakogaupodkaymaOP(outofplace)manlangkoto
Impairedsocial
interactionr/t
Selfconcept
disturbanceAEB
Discomfortinsocialsituations,receiveasatisfyingsenseofsocial
engagement,familyreportofchangesininteraction,dysfunctionalinteractionwithothers.
Definition:
Socialisolationistheconditionofalonenessexperiencedbytheindividualandperceivedasimposedbyothersandasanegativeorthreatenedstate;impairedsocialinteractionisaninsufficientorexcessivequantityorineffectivequalityofsocialexchange.
ShortTerm:1. Verbalize
awarenessoffactorscausingorpromotingimpairedsocialinteractions
2. Identifyfeelingsthatleadtopoorsocialinteractions.
3. Expressdesire
tobeinvolvedinachievingpositivechangesinsocialbehaviorsand
Independent:A.Assesscausative/contributingfactors.
B.Assistpatient/SOtorecognize/makepositivechangesinimpairedsocialandinterpersonalinteractions.
a.Thismayresulttoconformingorrebelliouspattern/behaviorwhilenotingprevalentinteractionpattern.b.Oncerecognized,clientcanchoosetochangeashelearnstolistenandcommunicateinsociallyacceptableway.
After14daysofNursePatientInteraction,the
clientwillbeableto:
VerbalizefeelingthatleadtopoorsocialinteractionGOALMET
Involveinsocialinteraction.GOALMET
Identifyselfpositivereinforcementforthechangesthatareachieved.
-
N C P |2japonsatripnila.Objective: Discomfortinsocialsituation
Donotaskquestion
Observedlackofattentionduringactivities
Insufficientorexcessivequantityorineffectivequalityofsocial
exchange.
Source:NursesPocket
Guide10thEditionbyMarilynnE.Doenges,MaryFrances
Moorhouse,AliceC.Murr
interpersonalrelationships.
LongTerm:4. Giveself
positivereinforcementforchangesthatareachieved.
5. Developsocial
supportsystem;useavailableresourcesappropriately.
C.Workwithclienttoalleviateunderlyingnegativeselfconcepts
Collaborative:D.Promotewellnessbyseekingcommunityprogramsforclientinvolvementthatpromotepositivebehaviorstheclientisstrivingtoachieve.
c.Negativeselfconceptifleftunresolvedoftenimpedepositivesocialinteractions.Attemptsattryingtoconnectwithanothercanbecomedevastatingtoselfesteemandemotionalwellbeing.D,Thereisadirectcorrelationbetweenthemusicalportionofthebrainandthelanguagearea,andtheuseoftheseprogramsmayresultinbettercommunicationskills.
GOALMET
Assessforenvironmentalwithdraw(timespentinroomversustimespentwithothers).GOALMET
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N C P |3
NURSINGCAREPLAN#2
ASSESSMENT NURSINGDIAGNOSIS
RATIONALE DESIREDOUTCOME
NURSINGINTERVENTION
JUSTIFICATION EVALUATION
ActualCues
Subjective:Thepatientverbalized,Nahuyanakokisakagnaguiltysanapanghimuko,,Walakopulosya..Lanakoputoro.Objective: Emotionallystressed. Facialgrimace
ChronicLowSelf
Esteemr/t
Feelingsofabandonmentsecondaryto
separationfromsignificantother/s
AEBLongstandingself
negatingverbalizations,Expressionsofshameandguilt,
Poorbodypresentation(eyecontact,posture,movements)
Nonassertive/passive
Definition:Longstandingnegative
selfevaluation/feelingsaboutselforselfcapabilities.
Developmentofanegativeperceptionofselfworthinresponsetoa
currentsituation.
Lowselfesteem
disturbancedescribeasnegativefeelingsabout
themselves,includingthe
lossofconfidenceandselfesteem,senseoffailuretoreachthedesire,selfcriticism,reduced
ShortTerm:1. Acceptsuppor