CASE PRESENTATION

INTRODUCTION - As a part of our study I am posted in GYANIC

WARD ward there I have assigned my patient Mrs. Nirmala Soni, she is
admitted on 4 February 2023 in bisahu das medical college korba with the
complain of aggressive behavior, laugh and talk by self since 2-3 weeks.

BASELINE DATA OF THE PATIENT-

Name - Mrs. Nirmala Soni
Age - 19 years
Sex - Female
Religion - Hindu
Educational status - 8th passed
Address - Vill- Pamgarh, Dist- Janjgir - Champa
Registration no. - 3254/211
DOA - 04 February 2023
Ward no. - gyanic ward
Bed no. - side room
Diagnosis - Post Partum Psychosis
Name of the operation - Not performed any surgery
Doctor consultant - Dr. Nilima mahapatro

CHIEF COMPLAINS - aggressive behavior and violent behavior, laugh

and talk by self since 2-3 weeks.

HISTORY OF THE CLIENT-

OBSTETRIC HISTORY-

Present obstetric history-

i) Para - 1
ii) Gravida - 1
iii) Mode of Delivery _ Normal vaginal delivery
iv) Term – Full term delivery
v) Presentation – Vertex presentation
vi) Birth weight – 2.7 kg
vii) Sex of baby – Male
viii) Apgar score – 8

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 ix) Any complication – No any complication occurs
Past obstetric history- No past obstetric history is present.
FAMILY HISTORY-
Type of family - My client lives in a joint family.
No. of family members - 10 members are living in her family.
Any genetic disorders in the family- No any genetic disorder is present in
my client’s family.

S.No. Name of the Age Sex Relationship Immunization Health

persons with the status status
client

1. Mr. Sampat 57 yrs Male Father in law - healthy

lal
healthy
2. Mrs. Laxmi 50 yrs Femal Mother in law - healthy
e
3. Mr. Sunil 24 yrs Husband - unhealthy
Male
4. Mrs. 19 yrs Client - healthy
Nirmala Femal
e
5. Mr. Bablu 22yrs Brother in law - healthy

6. Ms. 20 yrs Male Sister in law - healthy

Kausalya
Femal
7. Mr.Gulshan 18 yrs e Brother in law - healthy

8. Mr.Mohan 16 yrs Brother in law - healthy

Male
9. Mr. Sumit 14 yrs Brother in law - healthy
Male
10. Mr. Rehan 1monts Son Given acco- healthy
Male rding to age

Male

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Family tree-

Mr. Sampat lal Mrs. Laxmi

(57 yrs) (50 yrs)

Mr. Sunil Mrs. Nirmala

(24 yrs) (19 yrs) Mr. Bablu Mr. Kausalya Mr. Gulshan Mr.
Mohan

(22yrs) (20 yrs) (18 yrs) (16

yrs)

Mr. Sumit

(1 month)

INDEX:-

Male -

Female -

Female patient -

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SOCIO ECONOMIC HISTORY- my client’s family income is 20,000 /
month, two members are earning in her family, no other social support is
having and having good relationship with neighbors.
ENVIRONMENTAL HISTORY- my client’s lives in a semi pakka house
and having adequate ventilation, electricity facility is available in my client’s
house, they are using tape water, and having open drainage system, sanitary
facility is available in my client’s house.
PERSONAL HEALTH HISTORY- my client’s oral hygiene is good she
brushes her teeths ones in a day, and taken bath ones in a day with the use of
soap and water, and her grooming is poor and her sleeping pattern is altered,
her bowel and bladder habit is poor, she has no history of allergies, she did not
take alcohol and smoking. There is no health facility nearer to her house.
NUTRITIONAL HISTORY- my client is non vegetarian and she takes daily
breakfast, lunch and dinner and she did not like pumpkin and she likes egg and
ladyfinger.
PRESENT MEDICAL HISTORY- On 4 february 2023 my client comes
with the complain of aggressive and violent behavior, laugh and talk by self.
Dr. Nilima mahapatro seen her in psychiatric unit and admitted in gyanic
ward all lab investigation of my client is normal at the time of admission inj.
Serenace and phenorgon was given to my client and her conformatory
diagnosis is post partum psychosis.
PAST MEDICAL HISTORY- my client is not having any hereditary
disease. But she is having history of typhoid for which she takes treatment in
Dist. Hospital Janjgir Dr. Jagat treated her illness and she is feeling well.
PAST/PRESENT SURGICAL HISTORY- my client has no history of
past/present surgery.

GENERAL PHYSICAL EXAMINATION-

GENERAL APPERANCE-
Height : 5’
Weight : 45 kg
Consciousness : conscious
Body build : thin
HEAD-
Injury : no injury is present
Infection : no any infection is present
EYE-
Colour of sclera : white

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Conjuctiva : white
Infection : no any infection is present
Pallor : no paller is present
EAR-
Infection : no any ear infection is present
Ear wax : present
NOSE-
Common cold : not present
Sinusitis : not present
Rhinitis : not present
MOUTH-
Bleeding gums : not present
Teeth : clean
Tongue colour : yellowish
Foul smell : present
FACE-
Edema : absent
Cholesma : absent
NECK-
Neck veins : normal
Thyroid gland : normal, no enlargement
Lymph node : normal, no enlargement
RESPIRATORY SYSTEM-
Respiratory rate : normal
Chest pain : absent
Breathing difficulty : absent
Respiratory embarsment : absent
BREAST EXAMINATION-
Nipple condition : normal

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Areola : normal
Colostrums : absent
Lumps on breast : absent
Abscess : absent
Tenderness : present
CVS-
S1 : present
S2 : present
Murmur sound : absent
Pulse rate : normal
Chest pain : absent
GI SYSTEM-
Liver : normal, no enlargement
Spleen : normal, no enlargement
Nausea : present
Vomiting : present
Jaundice : absent
Burning sensation : absent
Indigestion : absent
Bowel sound : present normally
GENITOURINARY SYSTE-
Burning micturation : absent
Urinary incontinence : absent
Bleeding per vagina : absent
Discharge : absent
Infection : absent
MUSCULOSKELETAL SYSTEM-
Joint pain : absent
Ankle edema : absent

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Homen’s sign : absent
Varicose vein : absent

MENTAL STATUS EXAMINATION –

General appearance and behavior
 Appearance - looking one’s age,
 Facial expression - anxious facial
 Behavior - aggressive behavior.
 Eye to eye contact - not maintained
Speech
 Initiation - speaks when spoken to,
 Reaction time - normal
 Volume - decreased volume.
 Tone - monotonous
 Relevance - fully relevant
Mood - anxious and depressed
Thought
 Flow of thought - normal
 Content - no delusion
Perception - illusion and hallucination is not
present
Cognitive function
 Consciousness - conscious
 Orientation - oriented to time, place and person,
 Attention - aroused with difficulty,
 Concentration - having difficulty with sustained
concentration
 Memory - having good immediate, recent and remote
memory.
Insight - she is aware about her illness
Judgment - she is having poor judgment
Diagnostic formulation - post partum psychosis

VITAL SIGN-
VITAL SIGN PATIENT VALUE NORMAL VALUE REMARK
Temperature 98.6OF 98.6 OF normal
Pulse 76 b/m 70-80 b/m normal
Respiration 18 b/m 16-20 b/m normal

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BP 120/80 mmHg 120/80 mmHg normal

LAB INVESTIGATIONS-
S.N. PARAMETER CLIENT’S VALUE NORMAL VALUE REMARKS

1. R. Glucose 70 mg/dl Less than 160 mg/dl Normal

2. Urea 21mg/dl 13-45 mg/dl Normal
3. Creatinine 0.5 mg/dl 0.6-1.5 mg/dl Normal
4. Bilirubin(total) 0.6 mg/dl 0.1-1.2 mg/dl Normal
5. Bilirubin (direct) 0.3 mg/dl 0.0-0.3 mg/dl Normal

6. SGOT 31 U/L 5.0-34U/L Normal

7. SGPT 27 U/L 0.0-40U/L Normal
8. Alkaline 76 U/L 15-112 U/L Normal
phosphate
10. Total protein 6.8gm/dl 6.0-8.3 gm/dl Normal
11. Albumin 3.6 gm/dl 3.2-5.0 gm/dl Normal
12. Sodium 145mmol/l 135-145 mmol/l Normal
13. Potassium 3.5 mmol/l 3.5-5 mmol/l Normal
14. Hb 11.4gm 12-14 gm Low
15. WBC 6000/cumm 4000-11000/cumm Normal
16. DWBC
Polymorph 67% 40-70% Normal
Lymphocyte 30% 20-40% Normal
Monocytes 01% 2-4% Normal
Eosinophil 02% 0-2% Normal
17. ESR 15 mm after 1 hr Less than 30 mm after Normal
1hr

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 MEDICATIONS-
S. N Drug name Dose Route Time Mechanism of action Side effect Nsg. Responsibility

1. Inj. Haloperidol 2 ml IV BD An antipsychotic, agent that Blurred vision,dry mouth,  Assess patient behavior and
blocks postpsynaptic dopamine drowsiness, EPS. emotional status.
receptors, interrupts nerve
impulse movement and  Give IV push at a rate of 5
increase turnover of dopamine mg/minute.
in the brain.
 Instruct the patient to rise slowly
from a lying or sitting position.

 Take history of hypersensitivity to

antihistamine.

2. Inj.Phenorgon 2ml IV BD Anticholinergic effect, they Dizziness, drowsiness,  Instruct to avoid driving.
prevent blocks the action of anxiety, blurred vision,dry
acetylcholine thus reduce mouth, weight gain,  Maintain fluid intake.
nausea and produce sedation. constipation
 Obtain liver function test result.

Nursing responsibility

 Monitor B.P.

 Instruct the patient to maintain a

healthy diet and exercise.
Mechanism of action

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S.N. Drug name Dose Route Time Side effect  Assess the patient’s B.P, pulse
Antagonizes alpha-adrenergic, rate, and respiration.
3. Tab. Olanzapine 10 mg PO BD dopamine histamine Agitation, insomnia,
mascarinic and serotonin headache, orthostatic  Assist the patient with ambulation.
receptors. Produces hypotension, dizziness.
anticholinergic, histamine and  Instruct the patient to change
CNS depressant effects. position slowly.

It binds to an allosteric
4. Tab. Lorazepam 2mg PO BD ionotropic receptors in the Dizziness, confusion,
CNS, binding potentiates the peripheral edema,
effects of the inhibitory GI disturbance.
neurotransmitter GABA.

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DISEASE CONDITION:-
INTRODUCTION- Postpartum psychosis is a rare psychiatric emergency in which symptoms of high mood and racing thoughts
(mania), depression, severe confusion, loss of inhibition, hallucination and delusion set in, beginning suddenly in the first two week
after childbirth. The symptoms vary and can change quickly. The most severe symptoms last from 2 to 12 weeks and recovery takes 6
months to a years.

ANATOMY AND PHYSIOLOGY:-

Fig:- The Brain
Cerebrum:- This is the largest part of the brain and it is divided into right and left cerebral hemispheres, Deep within the brain the
hemispheres are connected by a mass of white matter called corpus callosum.Each hemisphere of the cerebrum is divided into lobes:
frontal lobe, parietal lobe, temporal lobeand occipital lobe.
Function:-
 Mental activities involved in memory, intelligence, sense of responsibility, thinking, reasoning, moral sense and learning.
 Sensory perception, including the perception of pain, temperature, touch, sight, hearing, taste and smell.
 Initiation and control of skeletal muscle contraction and therefore voluntary movement.

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Thalamus:- this consists of two masses of gray and white matter situated within the cerebral hemispheres just below the corpus
callosum.
Function:-
The thalamus relays and redistributes impulses from most parts of the brain to the cerebral cortex.
Hypothalamus:-
This is a small but important structure which weights around 7g and consists of a number of nuclei.It is situated below and infront of
tha thalamus, immediatel above the pituitary gland.
Functions:- the hypothalamus includes control of:
 The autonomic nervous system
 Appetite
 Thrist and water balance
 Body temperature
 Emotional reactions (eg, pleasure, fear etc.)
 Sexual behaviour
 Sleeping and walking cycle.
BRAIN STEM:
Midbrain:-
The midbrain is the area of the brain situated around the cerebral aqueduct between the cerebrum above and the pons below.
Function:-
It relay stations for the ascending and descending nerve fibers.
Pons:-
The pons is situated infront of the cerebellu, below the midbrain and above the medulla oblangata.it consists mainly of nerve fibers.
Function:-
 Act as relay stations.
 Pneumotaxic centers
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  Apnoustic centers.
Medulla oblangata:-
The medulla extends from pns above and is continous with the spinal cord below. It is about 2.5 cm long.
Functions:-
 Cardiovascular center.
 Respiratory center
 Reflex center of vomiting, coughing, sneezing and swallowing
Cerebellum:-
The cerebellum is situated behind the pons and immediately below the posterior portion of the cerebrum.it is ovoid in shape and has
two hemispheres.gray matter forms the surface of the cerebellum and the white matter lies deeply.
Functions:-
Coordination of voluntary muscular movement, posture and balance.
DEFINITION-
According to scribd.com
“Postpartum psychosis is a mood disorder in which feelings of sadness, loss anger or frustration interfere with everyday life for an
extended time.”
According to nurselabs.com
“A feeling of sadness that occurs for more than a year after the postpartum period and interferes with the normal functions of the
mother is called postpartum psychosis.”
INCIDENCE AND PREVALENCE-
Postpartum psychosis affects approximately 1-2 per 1000 births. The prevelance of postpartum psychosis in general population is
10% among pregnancies.
RISK FACTORS- Exact cause of post partum psychosis is unknown.

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 In Book In Patient

 Early age of pregnancy Absent

 Old age of marriage Absent

 Family history of psychiatric illness Absent

 Personal history of psychiatric illness Absent

 Stress Present

 Lack of support system Absent

 Improper management of labor Absent

PATHOPHYSIOLOGY-

An anticlimactic feeling is experienced by the woman after birth

Hormonal changes in estrogen, progesteron and gonadotropin- releasing

hormone rises and falls

Post partum psychosis

CLINICAL MANIFESTATION-

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 In Book In Patient

 Hallucination- it is a perception in the absence of Absent

external stimulus.

 Delusion- it is a false belief Absent

 Mood swing- it is an extreme or rapid changes in Present

mood.

 Feeling suspicious- feeling that somebody has done Present

something wrong.

 Restlessness- unable to stay to be quite and calm. Present

 Confused- inability to think or reason in a focused, Present

clear manner.

 Insomnia- inability to sleep. Present

 Suicidal or infanticide threats Absent

 Anxiety- feeling of worry

Present

MANAGEMENT-

In Book In Patient
1. Prevention

 Healthy life style o My client’s life style is healthy

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 o My client’s having poor partner
 Partners support support

 Family support. o My client’s having poor family

support
 Effective management of labor o My client’s labor management
was good

2. Medical management
 Antipsychotic drugs:- Antipsychotic drugs
o Chlonazapine o Haloperidol
o Thioredazine o Olanzapine
o Haloperidol o Lorazepam
o Loxapine
o Clozapine
o Risperidone
o Olanzapine
o Reserpine
o Lorazepam
Sedative drugs
 Sedative drugs:-
o promethazine
o Diazepam
o Chlonazepam
o Lorazepam
o Midazolam
o Zolpidem
o Zopiclone
o Phenobarbitone
o Thopentone
o Promethazine
o Melatonin

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 NURSING MANAGEMENT-
 Assess the women’s psychological health
 Assess client’s history of illness
 Provide counseling to client and her family.
 Educate the family members about client’s condition and disease process and management.
 Provide medication as per doctor’s order.

NURSING THEORY APPLICATION-

NURSING PROCESS FOR MRS. NIRMALA SONI WITH POSTPARTUM PSYCHOSIS USING ROY’S ADAPTATION
MODEL

Input control process effectors output

*Reassurance
Psychological Adaptive
*aggressive-ness function
Angry and
*Violent *Calm and safe aggressive
* Anger environment behavior
*Poor social
reduced
* Lack of interaction *Empathy
and inter-
control towards the
*anxiety personal
client
*Poor relationshi
interpersonal *Reduce enviro- p
relationship nmental stimuli improved

*Lack of Self concept

knowledge
Health education
regarding disease
17
condition and
management Effective
response
18
 Nursing process for Mrs.Nirmala Soni with Postpartum Psychosis using Roy’s Adaptation model

Adaptation is used by Roy’s to represent human as adaptive system. The human adaptive system has inputs of stimuli & adaptation
level, output as behavioral responses that serve as feed back & control processes known as coping mechanisms.
The human adaptive system has input coming from the external environment as well as within the system. Roy’s identifies input as
stimuli & adaptation level. Along with stimuli, the adaptation level of human system act as an important internal input to that system as
an adaptive system. Adaptation level is the combining of stimuli that represents the condition of life processes for the human adaptive
system. Outputs of human adaptive system are behavioral responses. Output responses can be both external & internal ; thus these
responses are the system’s behaviors.
This theory is viewing the humans as adaptive system. The human adaptive system in a holistic perspective as holism from the
underlying philosophic assumptions of the model.
Mr. Beeru was suffering from acute renal failure & he needs holistic health care. By this theory application for the patient, the patient was
able to adopt with the situation or disease condition & performs the daily activity & relieved from weakness & improved renal function &
got effective response with the treatment given.

 System-a set of parts connected to function as a whole for some purpose.

19
  Stimulus-something that provokes a response, point of interaction for the human system and the environment
 Focal Stimuli-internal or external stimulus immediately affecting the system
 Contextual Stimulus-all other stimulus present in the situation.
 Residual Stimulus-environmental factor, that effects on the situation that are unclear.
 Regulator Subsystem-automatic response to stimulus (neural, chemical, and endocrine)
 Cognator Subsystem-responds through four cognitive responds through four cognitive-emotive channels (perceptual and
information processing, learning, judgment, and emotion)
 Behavior -internal or external actions and reactions under specific circumstances

Physiologic-Physical Mode

 Behavior pertaining to the physical aspect of the human system

 Physical and chemical processes
 Nurse must be knowledgeable about normal processes
 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)

Self Concept-Group Identity Mode

 The composite of beliefs and feelings held about oneself at a given time. Focus on the psychological and spiritual aspects of
the human system.
 Need to know who one is, so that one can exist with a state of unity, meaning, and purposefulness of 2 modes (physical self,
and personal self)

Role function Mode

 Set of expectations about how a person occupying one position behaves toward a occupying another position. Basic need-
social integrity, the need to know who one is in relation to others.

Interdependence Mode

 Behavior pertaining to interdependent relationships of individuals and groups. Focus on the close relationships of people and
their purpose.
 Each relationship exists for some reason. Involves the willingness and ability to give to others and accept from others.
 Balance results in feelings of being valued and supported by others. Basic need - feeling of security in relationships

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Adaptive Responses-promote the integrity of the human system.

Ineffective Responses-neither promote not contribute to the integrity of the human system

Copping Process-innate or acquired ways innate or of interacting with the changing of environment

Adaptive Modes

A. Persons

 Physiologic
 Self Concept
 Role Function
 Interdependence

B. Groups

 Physical
 Group Identity
 Role Function
 Interdependence

Role Function Mode

 Underlying Need of Social integrity

 The need to know who one is in relation to others so that one can act
 The need for role clarity of all participants in group

Adaptation Level

 A zone within which stimulation will lead to a positive or adaptive response

 Adaptive mode processes described on three levels:
 Integrated
 Compensatory
21
  Compromised

Integrated Life Processes

 Adaptation level where the structures and functions of the life processes work to meet needs
 Examples of Integrated Adaptation
 Stable process of breathing and ventilation
 Effective processes for moral-ethical-spiritual growth

Compensatory Processes

 Adaptation level where the cognator and regulator are activated by a challenge to the life processes
 Compensatory Adaptation Examples:
 Grieving as a growth process, higher levels of adaptation and transcendence
 Role transition, growth in a new role

Compromised Processes

 Adaptation level resulting from inadequate integrated and compensatory life processes
 Adaptation problem
 Compromised Adaptation Examples
 Hypoxia
 Unresolved Loss
 Stigma
 Abusive Relationships

Mr. Pradeep Kumar with myocardial infarction using Roy’s Adaptation model.

Input :
 Anger
 Lack of control
 Lack of interpersonal relationship
 Lack of knowledge
Control process :
 Reassurance
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  Agresiveness
 Violence
 Poor social interaction
 Anxiety

Effectors :

Physiological function
 Calm and safe environment
 Empathy towards the client
 Reduce enviro-nmental stimuli
Self concept
Health education regarding disease condition and management and psychological support.

Output : client adopt with treatment improved general condition & effective response from drugs.

Adaptive
Angry and aggressive behavior reduced and inter-personal relationship improved
Effective response
Antipsychotic drugs & other supportive measures psychotherapy.

Mrs.Nirmala Soni was suffering from Postpartum Psychosis. client adopt with treatment improved general condition & effective response
from drugs.
The first area of focus is human as adaptive system, both as individuals & in groups. The model offers a point of view or paradigm for
shaping nursing activities. The focus of nursing relationships & interactions can be at the level of individual, group, organizations,
communities, & society in which they are included any of these may be considered a human system & each is considered by the nurses as
a holistic adaptive system.

23
NURSING CARE PLAN-
24
Assessment Nursing Goal Planning Implementation Rationale Evaluation
Diagnosis

Subjective data- Risk for To  Assess the  Assessed the  Helps to On evaluation I
Client’s family violent reduce general general condition maintain base found that risk of
member told that behavior the risk condition of of client. line data for injury is reduced.
client is having related to of injury client. further
hyperactivity disease intervention
condition  Place the sharp  Placed the sharp  Help to reduce
Objective data- as articles away articles away the risk of
on manifestation manifested from the client. from the client. injury.
I found that by
client’s having hyperactiv  Not leave the  Not leaved the  Reduce the risk
violent behavior. ity child alone with child alone with of injury to
client. client. child.

 Provide  Provided  Helps to

psychological psychological improve
support to support to client. understanding.
client.

 Administer  Administered  Help to sleep

sedative to sedative to client. thus reduce the
client. risk of injury.

25
Assessment Nursing Goal Planning Intervention Rationale Evaluation
Diagnosis

Subjective data- Ineffective To  Assess the  Assessed the  Help to plan On evaluation I
Client’s mother copping improve general general further found that clients
told that my related to copping condition. condition. intervention. copping strategy is
client is irritated disease strategy improved.
condition of client.
as  Provide  Provided  Help to
manifested psychological psychological cooperate in
by support. support. treatment.
Objective data- conversati
On conversation on
I found that  Provide stress  Provided stress  Help to reduce
client’s having reduction reduction clients stress.
ineffective strategies. strategies.
copping strategy.

 Help the client  Help the client to  Help to cope

to use coping use coping about her
strategies. strategies. condition.

26
Assessment Nursing Goal Planning Implementation Rationale Evaluation
Diagnosis

Subjective data- Altered To  Assess the  Assessed the  Help to plan On evaluation I
Client’s family family improve behavior of behavior of further found that family
members told pattern family family family members. intervention. process is
there is having related to pattern. members. improved.
conflict in family disease
condition  Provide  Provided  Help to increase
manifested psychological psychological understanding of
by support to support. family members.
conversati them.
on
Objective data-
On conversation  Educate them  Educated them  Help to
I found in my about client’s about client’s cooperate with
client’s family condition. condition client.
pattern is altered

Assessment Nursing Goal Planning Implementation Rationale Evaluation

Diagnosis

Subjective data– Self care To  Assess the  Assessed the  Help to plan On evaluation I
Client’s relative deficit improve general general further care. found that client’s
told that client is related to self care condition. condition. self care is
unable to do self disease of client. improved.
care condition
as  Assess the  Assessed the  Help to give

27
 manifested understanding understanding instruction about
by level of client. level of client. self care.
Objective data- Observatio
On observation I n
found that
client’s having  Advice to do  Adviced to do  Help to improve
self care deficit. self care based self care based on self care and
on understanding. activity of daily
understanding. leaving.

Assessment Nursing Goal Planning Implementation Rationale Evaluation

Diagnosis

Subjective data- Altered To  Assess the  Assessed the  Help to maintain On evaluation I
Client’s relative sleeping improve general general baseline data. found that client’s
told that client is pattern sleeping condition of condition. sleeping pattern is
not taking proper related to pattern client. improved.
sleep lifestyle
disruption  Monitor the  Monitored the  Help to plan
as sleeping hours sleeping pattern further
manifested of client. of client intervention.
by
Objective data- observatio  Provide clean  Provided  Improve feeling
On observation I n bed. Clean bed. of wellbeing.
found that
client’s having  Provide calm  Provided calm  Help to feel
altered sleeping and quite and quite relaxed.
pattern. environment . environment.

 Provide soft  Provided soft  Help to

28
 music to client. music to client. concentrate on
sleep.

 Administer  Administered  Help to take

sedative drug. sedative drug. proper sleep.

Assessment Nursing Goal Planning Implementation Rationale Evaluation

Diagnosis

Subjective data- Imbalance To  Monitor  Monitored  Help to plan On evaluation I

Client’s family nutrition improve client’s weight. client’s weight. further found that client’s
member told that less than nutrition intervention. health status is
client is looking body al status improved.
thin requireme of client.  Monitor daily  Monitored daily  Maintain
And weak nt related intake and intake and output. baseline data.
to disease output.
condition
Objective data- as  Advice to take  Adviced to take  Help to improve
On monitoring manifested balance diet. balance diet. health status.
weight I found by
that client’s monitoring  Advice to take  Adviced to take  Help to maintain
having low body weight adequate fluid adequate fluid hydration.
weight. intake. intake.

 Administer IV  Administered IV  Help to maintain

infusion. infusion. fluid and
electrolyte.

29
Assessment Nursing Goal Planning Implementation Rationale Evaluation
Diagnosis

 Assess the  Assessed the  Help to plan On evaluation I

Subjective data- Deficit To understanding understanding of further found that client’s
Client’s relative knowledge educate of client’s client’s family. intervention. family member’s
told that they are related to client’s family. knowledge about
having lack of disease relative disease condition is
knowledge about condition about  Educate them  Educated them  Help to improved.
disease condition as disease about disease about disease understand
manifested conditio condition. condition. about client’s
by n. condition.
Objective data- conversati
On conversation on
I found that  Educate them  Educated them  Help to
client’s family about about cooperate in
member has lack management of management of clients
of knowledge disease disease condition. treatment.
about disease condition.
condition

30
 Assessment Nursing Goal Planning Implementation Rationale Evaluation
Diagnosis

Subjective data- impaired To  Assess the  Assessed the  Help to plan On evaluation I
parenting improve general general condition further found that client’s
related to parentin condition of of client. intervention. parenting process
inability to g of client. is improved.
perform client
activities  Provide  Provided  Help to increase
of daily psychological psychological understanding
living as support to support to client. level of client.
Objective data- manifested client.
On observation I by
found that observatio
client’s having n  Identifying  Identifying  Help to identify
impaired understanding understanding to give time to
parenting. level of client. level of client. spend with her
child.

 Give time to  Given time to  Help to improve

client spend client spend with parenting of
with her child her child. client.

31
COMPLICATIONS-

In Book In Patient
 Mood alteration-- it is an Present my client is suddenly anger and
extreme or rapid changes in happy
mood.

 Halucination- it is a perception Absent

in the absence of external
stimulus.

 Maternal mortality- death of a Absent

mother

PROGNOSIS-
1st day:- my client is hyperactive and anxious.
Care given to client:-
 Monitor vital sign.
 Provide calm and quite environment.
 Administering sedative drugs to client. Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg

Outcome:-
 Vital signs are normal.

Temperature Pulse Respiration

98.6oF 74 beats/minutes 14 b/minutes

 Client feels relaxed and sleep well.

2nd day:- my client is crying for her baby and looking weak.
Care given to patient:-
 Monitor vital sign
 Provide time to spent with her baby and
 Giving her balance diet and
 Administering IV infusion of DNS.
 Administered medications as per order.
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
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 o Lorazepam-2mg

Outcome:-
 Vital signs are normal.

Temperature Pulse Respiration

98.6oF 72 beats/ minutes 14 b/minutes

 She felt good after she meet her child.

 Her hydration is maintained and weakness is reduced.
3rd day:- my client is again hyper violent.
Caregiven to patient:-
 Monitor vital sign.
 Administer sedative drugs as per doctors order.
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg

Outcome:-
 Vital signs are normal.

Temperature Pulse Respiration

98.6oF 72 beats/ minutes 14 b/minutes

 Patient is sedated and feeling sleepy thus taking sleep.

4th day:- I found that client is having self care deficit and need to change the
cannula.
Care given to client:-
 Monitor vital sign.
 Administer injection and medication as per order
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg

 Change the client’s cannula

 Help her in self care.

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Outcome:-
 All vitals are normal.

Temperature Pulse Respiration

98.6oF 74 beats/minutes 14 breaths/minute

 After changing cannula client feels better.

 After taking medication client taken sleep.
5th day:- on 5th day my client is looking good and cooperate in care.
Care given to client:-
 Monitor vital sign.
 Provide neat and clean bed to client.
 Administered injection and medication as per doctor’s order.
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg

Outcome:-
 All vitals are normal

Temperature Pulse Respiration

98.6oF 72 beats/ minutes 14 b/minutes

 Client is feeling better.

6th day:- my client is looking good and feeling better.
Care given to client:-
 Monitor vital sign.
 Administer medication as doctor’s order.
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg
 Educated the family to cooperate with client’s condition.
Outcome:-
 All vitals are normal.

Temperature Pulse Respiration

34
 98.6oF 72 beats/ minutes 14 b/minutes

 After taking medication my clients feels good and take rest.

7th day:- on 7th day client is looking good and feeling better.
Care given to patient:-
 Monitored vital signs
o Administer medications as doctor’s order.
o Haloperidol-2ml
o Phenorgan-2ml
o Olanzapine-10mg
o Lorazepam-2mg

Outcome:-
 All vitals are normal.

Temperature Pulse Respiration

98.6oF 72 beats/ minutes 14 b/minutes

 Taking medication and feeling good.

HEALTH EDUCATION-
 Advice the client to take balance diet.
 Advice the client to take proper rest and sleep at lease 8 to 10 hours daily.
 Advice the client to avoid stress.
 Advice to take 8-10 glass of water per day.
 Advice to do exercise daily.
 Advice to take medication daily as per order.

35
CONCLUSION- My client Nirmala Soni is admitted with the complain of
violent behavior. Dr. Gaurishankar Singh treating her. Dr. prescribed haloperidol,
phenargon, olanzapin and promethazine drugs to treat her condition. And day by
day her condition is improved and feeling better and discharged on 11 February
2018.

36
BIBLIOGRAPGY-
1) Davis F.A., “DAVIS’S DRUG GUIDE FOR NURSES”,9th
edition,2005,Robort Mortone publisher;place: Philadelphia,Pg-489.
2) Dutta D.C., “TEXTBOOK OF OBSTETRICS”,2001, New central book
agency publisher; place: New Delhi,pg-442.
3) Shreevani R., “MENTAL HEALTH NURSING,”3rd edition,2013,
jaypee brothers Medical publisher; place:New Delhi, Pp-316-317.
4) Udaykumar Padmaja, “PHARMACOLOGY FOR NURSES,” 3rd
edition, 2013, jaypee brothers Medical publisher; place: New Delhi, Pp-
139.
5) Wilson and ross, “ANATOMY AND PHYSIOLOGY,”11th edition,2010,
Churchill Livingstone publisher; place: U.S. America, Pp-149-154.
6) www.rightdiagnosis.com
7) Nursingcareplan.blogspot.in
8) http://googleweblight.com
9) http://pubchem.ncbi.nlm.nih.gov
10) http://www.everydayhealth.com
11) www.scribd.com
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