i

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.

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.

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 -

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

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

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.

2

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.

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

4

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.

5

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'

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

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

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

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).

10

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

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

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

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

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

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

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

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.

18

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.

19

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

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

21

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.

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

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

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,

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.

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

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.

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.

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

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

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

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

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

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

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

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?

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

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.

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

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

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

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

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

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.

45

Formula for Mean

The mean is obtained by dividing the summation of scores in

all the questions in the assessment tool.

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

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

Figure 3. Evaluative Scale of Mean During Initial 47Assessment

Relatively Severe Tendency to Loneliness

1 2 3 4

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.

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.

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

51

orprivacy.

8. Encourageclienttoventilatefeelingsinwhateverwayiscomfortableverbalandnonverbal.Lettheclientknowyouwilllistenandacceptwhatisbeingexpressed.[Expressingfeelingsmayhelprelievedespair,hopelessnessandsoforth.Feelingsarenotinherentlygoodorbad.Youmustremainnonjudgmentalabouttheclientsfeelingsandexpressthistotheclient.]

9. Teachtheclient

aboutproblemsolvingprocess:explorepossibleoptionsexaminetheconsequences,ofeachalternative,selectandimplementanalternative,andevaluatetheresult.[Theclientmaybeawareofasystematicmethodforsolvingproblems.Successfuluseof

52

problemsolvingprocessfacilitatestheclientsconfidenceintheuseofcopingskills.]

10.Providepositive

feedbackateachstepoftheprocess.Iftheclientisnotsatisfiedwiththechosenalternative,assisttheclienttoselectanotheralternative.[Positivefeedbackateachstepwillgivetheclientmanyopportunitiesforsuccess.Encouragehimtopersistinproblemsolving,andenhanceconfidence.Theclientcanalsolearntosurvivemakingamistake.

DependentNursingAction:

11.Monitorintakeof

dailymedication(Olanzapine,Haloperidol,Valpros)[Assuresadherencetomedication.Observanceof10rightsofgivingmedication

53

shouldbefollowed.]

CollaborativeNursingAction:

12.Collaboratewith

theRehabilitationnurseintheprovisionofdailymedication.[Continuumofcare.]

13.Review

endorsementprocedureandreferralprocessesfollowedinNODRC

14.Coordinatewiththepsychiatrist,Administrator,nurseandauthorizedpersonsregardingeveryinteractionandresultsorprogresswiththeinterventiontakenon theclient.

15.Assistinpatients

takingofassessmenttoolsandfollowupresultstobeutilizedasatoolindeterminingnursepatientinteractionandintervention.

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.

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.

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

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

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.

59

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.

60

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Cacioppo JT, et al. Loneliness within a nomological net: An

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Dussault, Marc, and ric Frenette. "Loneliness and Bullying

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in the care of a patient. Professional Nurse.

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Work (7th ed., pp. 338). St. Louis, Mosby. Retrieved

from: http://en.wikipedia.org/wiki/Hildegard_Peplau

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Health Nursing. 1998;5:193196. [PubMed]

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trends. 2011 Available at

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Peplau, H.E. (1954). Utilizing themes in nursing

situations. American Journal of Nursing, 54, 325328.

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Russell DW. UCLA Loneliness Scale (Version 3): Reliability,

validity, and factor structure. Journal of Personality

Assessment. 1996;66(1):2040. [PubMed]

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2010, Posted on Tuesday, January 5th, at 3:37 am.

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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

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(2004). National consensus statement on mental health

recovery. Retrieved from

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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

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heet_7-23-2013.doc.

Taylor Carol, (2011). The Art & Science Of Nursing Care 4th

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Appleton-Century-Crofts.

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64

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

65

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

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

67

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

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

69

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.

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

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