1

CASE STUDY ON A PATIENT WITH BIPOLAR (MANIC DEPRESSION):

APPLICATION OF HELEN ERIKSONS MODELING AND ROLE MODELING

THEORY

A SEMINAL PAPER

PRESENTED TO

THE FACULTY OF THE GRADUATE SCHOOL

CEBU NORMAL UNIVERSITY

IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE

MASTERS OF NURSING

MAJOR IN

MENTAL HEALTH - PSYCHIATRIC NURSING

GRACE ANTONNETTE S. VERGARA

MARC 2017
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CHAPTER I
INTRODUCTION

BACKGROUND AND RATIONALE OF THE STUDY

Bipolar disorder, also commonly known as manic depression is a chronic,

recurrent illness that must be carefully managed throughout a persons life. This brain

disorder that causes unusual shifts in mood, energy, activity levels, and the ability to

carry out day- to day tasks frequently goes unrecognized, and people suffer for an

average of 6 years before receiving a proper diagnosis and treatment. Extreme mood

swings that include emotional high (mania or hypomania) and lows

(depression).Depressive mood may feel sad and hopeless and lose interest or pleasure

in most activities. When the mood shift in the other direction, patients may feel euphoric

and full of energy. This may occur few times a year or as often as several times a week

(NIMH, 2013).

About 1 in every 100 adults experienced bipolar disorder at one point in their life.

This starts at age 15 - 19, although this rarely starts in later life, men and women are

both affected equally. Although females are three times more likely to experience rapid

cycling and may have more depressive episode and more mixed episode than men.

Each year, 6 million adult in America are affected with this disorder, 2.6% of its

population is 18 years and older. Bipolar disorder is found in all races, ethnic groups,

and social classes (NIMH, 2013). The stigma is very real against the people with this

disorder.

In the study conducted by the World Health Organization, bipolar was estimated

to be the 7th leading cause of non-fatal burden in the world in 1990, accounting for3% of
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the total YLD (years live with disability), around the same percentage of chronic

obstructive lung conditions. In 2000, bipolar remains in the top 10 YLD at a global level

accounting to 2.5%. (http://www.who.int/healthinfo/statistics/bod_bipolar.pdf).

In the Philippines, there has been an increase of 10.8% per 100,000 people of

healthy life lost years with bipolar disorder since the 1990 and an average increase of

0.5% each year thereafter. For men, the health burden of bipolar peaks at 25-29, it

harms men at the lowest rate at age 10- 14. Women are harmed at the age of 30-34,

the least at age 10-14, the peak rate for women are higher compared to men.

(http://global-disease-burden.healthgrove.com).

Philippine General Hospital psychiatrist Norieta Calma-Balderama says bipolar in

the Philippines knows its prevalence but just couldnt know the exact number. Because

of the absence of comprehensive study about the disorder and the hint of having mental

illness in the family can cause reputation. (http://pcij.org/stories/an-illness-in-the-family/).

The exact cause of bipolar disorder is unknown. Although there are tests that can

verify bipolar disorder the current theory is that it principally is a biologic disorder that

occurs in a specific area of the brain and is due to a malfunction of the

neurotransmitters. It is usually spontaneously activated or triggered by environmental

stressors (Judith Swan, 2016). Biologic theories include genetic, biochemical, and

physiologic influences. Research has shown that a child with one parent with bipolar

disorder has 15 25% increased risk, having both parents will increase risk to 75%.

There are some biogenic neurotransmitters that is believed to cause bipolarity. The

faulty in regulation of one or two of these transmitters shows significant role in the
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balance of some hormones such as serotonin, dopamine, epinephrine, and

norepinephrine and these greatly affects human emotions (Judith Swan, 2016)

People with bipolar disorder usually experience intense emotional states that

occurs in a period of time called mood episodes. Each mood represents a drastic

change of a persons usual mood and behavior. Manic episode is characterized by joyful

or overly excited behavior while an extremely sad and hopelessness state is called

depressive episode. The symptoms of mania or a manic episode include: overly long

periods of feeling high or an overly happy or outgoing mood and extremely irritable.

Behavioral changes include: talking very fast, jumping from one idea to another, having

racing thoughts, being unusually distracted, increasing activities, such as talking on

multiple new projects, being overly restless, sleeping little or not being tired, having an

unrealistic belief in your abilities, behaving impulsively and engaging in pleasurable,

high- risk behaviors. During the depression phase, patients can be overly experience

long feeling sad or hopeless and loss of interest in activities once enjoyed, including

sex. Behavioral changes can include feeling overly tired or slowed down, problems in

concentrating, remembering and making decisions, being restless and irritable is also

experience, physiologic needs are also affected as they have changes in eating pattern,

sleeping, and suicide thoughts (New York state office of mental health, 2016).

DSM-V criteria for episodes of mania include a sustained abnormal mood plus

three or four manic behaviors. If the patient displays psychotic features or requires

hospitalization then the episode is automatically classifies as manic. A major depressive

episode is define by five or more depressive behaviors, present at the same time, for a
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least a two week period. At least one of the symptoms must be either a depressed

mood or a loss of interest or pleasure. This may last for months (BJP 2014, issue 62).

Add chronicity of the condition

The purpose of this study was to probe the applicability of the Modeling and

Role- Modeling Theory (MRM theory), through a case study, to understand and explore

the clients world to create a much reliable effective management of patients with bipolar

disorder. To provide holistic care to patients with bipolar, MRM theory enables the

nurses to care for and nurture clients with an awareness of and respect the uniqueness

of individual in coping with their stressors. Since this is a self care model, care is

modeled through the clients ability to recognize his/her disease and draw unique

interventions that could make him/her well. The application of this theory to a patient

with bipolar disorder will demonstrate how nursing care enable the client to recognize

and develop strengths in overcoming mental illness.

The unique and clear guidelines of collating data and analyzing date using a tool

based on MRM will enable the nurse to gain a deeper and thorough understanding of

the patients world and therefore promote an effective and client- centered management

that is solely unique and appropriate to the patients road to recovery and self growth.

The interpersonal and interactive aspect of this theory will create a purposeful sharing of

healthcare practitioners and other individuals that is directly involve in the patients

battle for this mental illness. Therefore, MRM theory is created to manage holistically in

helping patients to overcome stressors and directing them toward the wholeness and

unity of the clients body, mind, emotion and spirit.

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Theoretical - Conceptual Background

Nursing is a profession which is simultaneously art and science. What makes

nursing profession exciting and elusively frustrating is this fusion of art and science to

continually enhance peoples health. The goal to assist each client in their growth as

people, we need to both cultivate our scientific foundation and artful performance to

them. We can heighten our ability to practice both with our grounded theory. One fairly

drawn theory was developed to explicitly link together the concepts of with our

profession which mainly concern with: people, nursing, health and environment. The

theory called Modeling and Role Modelling, developed by Helen Erickson, Mary Ann

Swain, and Evelyn Tomlin, is a complex integration of several theories. This study will

look at on how these concepts and linkages through a bipolar patient in her depressive

phase. The theory integrates the art and science of nursing and be applied in the clinical

settings, in education, and in stimulating research. The use of this theory in a bipolar

patient will provide the nurses to deliver and document care in a way that will bring

holistic care to forefront wellness and health care. The theory, for the purpose of this

study, was adapted to illustrate how a patient with bipolar disorder was able to

overcome stress and assist the clients needs according to the roles identified by the

theory as facilitator, nurturer and having an unconditional acceptance.

This theory is developed by Helen Erickson, Evelyn M. Tomlin and Mary Anne P.

Swain. Published in 1983, her theory enables nurses to care and nurture each client
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with an awareness of and respect for the individuals uniqueness which exemplifies

theory- based clinical practice that focuses on the clients needs. MRM draws concepts

from Maslows theory of hierarchy of needs, Ericksons theory of psychosocial stages,

are the building blocks for MRM. The degree of which development tasks are resolved

is dependent on the degree to which human needs are satisfied. (Journal of advanced

nursing, 1989, 14,755-761). Based on Maslows hierarchical ordering of basin and

growth needs which drive behavior. When a basic need are met person perceives they

are met. Anxiety is secondary when needs are unmet; thus when a basic need is unmet,

a situation may produce as perceived threat, and physical or psychological distress and

illness may occur. When growth need satisfaction is not met or satisfied it usually

provides challenging anxiety and stimulate growth. Need to know and fear of knowing

are associated with meeting safety and security needs. On Eriksons theory, task

resolution depends on degree of need satisfaction. The resolution of each stage critical

tasks usually lead to growth and promoting trust or it can lead to mistrust that can

attribute ones ability to fully functional and able to respond in healthy way to stressors.

As age- specific task is met the person can build strengths and attitudes such as self-

control or willpower.

MRM is based on the assumption that all humans want to interact with others,

they want to carry our selected roles in society. Role- modeling uses the clients model

of world to plan interventions that meet his/her perceived needs, grow, develop and

heal. Role-Modeling requires that we aim to build trust, promote a positive orientation

and a sense of control, affirm strengths and set specific mutual goals. Our nursing goal

is to help people achieve quality, holistic health. The major concepts of MRM are also
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related to the underlying assumptions and philosophical believes on the commonalities

and differences among people among people.

Philosophical Assumptions

The commonalities of People

Holism, a commonality people share, which is the belief that people are more

than the sum of their parts. Instead, mind, body, emotion, and spirit function as one unit,

affecting and controlling the parts in dynamic interaction with one another. This means

conscious and unconscious processes are equally important. Therefore, health can be

perceived or define as a dynamic sense of well- being associated with self- fulfillment

and transcendence (Erickson, et al., 1983).

The basic needs of each individual satisfaction, growth, and Development.

Humans are in a continual state of change and have inherent behavior that drives

growth, satisfaction, adaptation and development. Growth is define as the changes of

body, mind, spirit that develop overtime. Development is define as a holistic synthesis of

the growth that is produce in the differences of the human body, ideas, social relations

and etc. When a person is given subsequent information, adequate emotional support

and empowered in making sound decisions, growth is potentially enhanced (Erickson,

et al., 1983).

Affiliated individuation is a concept unique to the MRM theory- one of the

commonalities of people- based on the belief that all people have an instinctual drive to

be accepted and dependent on support systems throughout life, while also maintaining
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a sense of independence and freedom (Erickson, et al., 1983). This study views the

patients affiliation with other people and support system while simultaneously remaining

independent in maintaining and coping with her identified stressors.

Attachment and Loss addresses the idea that people have an innate drive to

attach to objects that meet their needs repeatedly. They also grieve the loss of any of

these objects. The loss can be real, as well as perceived or threatened. Unresolved loss

leads to a lack of resources to cope with daily stressors, which results in morbid grief

and chronic need deficits. This concept of attachment and loss relates to the external

stressors of the patient and can be the source of the maladaptive coping mechanisms

that lead to mental disorder (http://mrmnursingtheory.org/definitions.html).

Psychosocial Stages, based on Erikson's theory, say that task resolution

depends on the degree of need satisfaction. Resolution of stage-critical tasks lead to

growth-promoting or growth-impeding residual attributes that affect one's ability to be

fully functional and able to respond in a healthy way to daily stressors. As each age-

specific task is negotiated, the person gains enduring character-building strengths and

virtues (http://mrmnursingtheory.org/definitions.html).

Cognitive Stages, based on Piagets theory, the thinking ability also develop in a

sequential order and useful in determining the developmental stage of a person. This

could be essential in identifying the patient in having difficulty in coping up with. Thus

keeping the information simple for a client (http://mrmnursingtheory.org/definitions.html).

The Difference among People

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The differences among people include their inherent endowment thats consists

of their genetic make-up during the prenatal and perinatal period that greatly influences

ones health status. Their unique model of the world, which is the persons perspective

of his or her own environment based on his/her past experiences, knowledge, and state

of life. Another most significant difference among people would be the way one adopt to

stress thats health and growth directed (http://mrmnursingtheory.org/definitions.html).

Adaptation Potential, this is the ability of an individual to cope with stressors.

Adaptation occurs as need is met, stress diminishes as one potentially built a new

resource. This could be predicted with an assessment model that delineates three

categories: arousal, equilibrium, and impoverishment. The resources of potentiality of

individual adaptation could be external or internal. Arousal could reflect any stressors

(anxiety and tension), when a body is under this stress it creates a response to balance

that could be either adaptive or maladaptive. Adaptation is a positive reaction while

maladaptive could signify a negative state of which a person react to a stressful stimuli,

that causes draining energies from the system. This can lead to impoverishment state in

which a person have diminished or depleted resource to draw upon growth.

Stress is unmet needs the body then creates a general response to stressful

stimuli in pattern involving endocrine, GI and lymphatic systems which Selye identified

as general adaptation syndrome (GAS). The three phases of GAS are the alarm

reaction, stage of resistance and stage of exhaustion. Stimuli may be perceived as

threatening or challenging (Lazarus); stressful or distressful (Selye). Engle identified

psychological reactions or stress as with the flight or fight response. He believed that

people responded to psychosocial effects. He emphasized that some stress are good
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stress and some are not so good. The resolution of stress requires adequate resources,

ones ability to mobilize adequate resources determines the outcome of the stress

response. Resources can be within the subsystem, it is not limited to a single

subsystem. In this study for example, the patient experience psychological illness that

affects her subsystem, her perception of development event of her life has affected her

physiological, emotional, cognitive, and spiritual subsystems

(http://nursekey.com/modeling-and-role-modeling-theory-in-nursing-practice/#bib88).

Self care knowledge, self care resources and self care action, are

important is the process of managing in responding to stressors. This includes what we

know about ourselves, our resources and our behaviors. MRM theory asserts at a

person knows what has made him or her sick or inferred with growth and what will help

him or her heal and optimized his or her effectiveness and promote his or her growth,

this is self- care knowledge. The strengths people develop and their support system and

social networks form the self- care resources. They respond to the continual changes

we are faced within life. Self care action is when we use our self- care knowledge and

our abilities to mobilize our resources.

Human being are complex. Identifying enduring characteristics from development

and basic needs satisfaction provides information in understanding human behavior.

Thus, another model was used in MRM that draws human responses to stressors, how

they adopt to it and how individual perform self-care when they are faced in this

situation.

APAM (Adaptive potential assessment model) was synthesized and

developed to assist in predicting an individuals potential to cope with stress. This

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multidimensional assessment strategy used by nurses in the implementation of MRM

theory (Erickson, et al., 1988). It describes differing abilities to mobilize coping

resources in stress and non-stress states using indicators to different state. APAM

model, stress state are distinguished from nonstress states. When a stimulus is

experienced as a challenge, it is a stressor; when experienced as threatening, it is a

distressor and leads to a maladaptive response. There are three categories identified in

APAM: arousal, equilibrium, and Impoverishment. When stress is experience leads to a

state of arousal. Arousal may be experienced by feelings of tenseness and

anxiousness, accompanied by elevations in blood pressures, pulse rate, respiration,

and motor-sensory behavior. From arousal the person may move to as state of

equilibrium or impoverishment. In a state of impoverishment, the individual experiences

marked feelings of tension and anxiety, with feelings or fatigue, sadness, or depression.

In addition to elevated pulse, respiration, blood pressure, and motor- sensory behavior,

there is an elevation in verbal anxiety. Equilibrium may be adaptive or maladaptive. In

adaptive equilibrium, the individual has normal vital signs and sensory-motor behavior,

expresses hope and has low or absent feelings of tenseness, fatigue, sadness, and

depression. In a state of maladaptive equilibrium, one may appear to be coping with

stressor, but the expenses of draining energy from another subsystem. Each state is

associated with different coping potentials or different abilities to mobilize coping

resources. Movement among the states, either to equilibrium or impoverishment,

depends on both the ability to mobilize resources and the presence of new stressors

(Peterson, Bredow, 2004).

Modeling and Role- Modeling

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There are several key components that comprise Modeling and Role- Modeling

Theory. Both are described to have aspects of both art and science. The art of modeling

is action taken by the nurse to develop an understanding of the clients perspective of

the world and its science is data collection analysis from which a model of the clients

world is constructed.

The art of role-modeling involves planning and implementing care based on the

data analysis. The planned and implemented care will be different for each client

because each individual is unique. The science of role-modeling involves using

knowledge of theory to plan and implement care. Together, the art and science of role-

modeling will result in assisting the individual in attaining, maintaining, or promoting

health through purposeful intervention (Erickson 1983).

Overall, people are alike in some ways and very different in others. Care is

offered that recognizes that clients have the knowledge and ability to understand what

has made them sick, as well as what will make them well. MRM provides a basis for

nursing care that truly puts the clients needs first and allow the nurse to offer holistic

care.

Similarities

Holistic Beings

Basic Needs of Development

Modeling and Role- Modeling

Differences Meeting the patient where they

are, as they are
General Makeup

World View

Stress Adaptation
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Figure 1.0. Illustration of MRM on drawing commonalities and difference of each

individuals in Modeling and Role- Modeling to meet holistic care. (Hertz, 1997)

Figure 1.0 illustrates assumptions and the philosophical views of MRM. Overall

people are alike in some ways and we are very different in others. We are like in our

holistic beings, we are transitioning into different stages of development. We are

maintaining a need for affiliated individuation. But we are also each unique and that

we have our own genetic make-up. Our own view of the world and own way of adopting

to stress. Thus, with this commonalities and difference nurses get to create on how to

model clients world and furthermore, assess and develop intervention through role

modeling. Modeling and Role Modeling focuses on assisting the individual mobilized

these sub-care resources by meeting the patient, where they are, as they are.

After the clients world has been modeled, the nurse facilitates and nurtures the

individual, in attaining, maintaining or promoting health through purposeful interventions.

Role- Modeling involves the planning and implementing care based on the date

analysis. The planned and implemented care will be different from each client because

each individual is unique. It involves using knowledge of theory to plan and implement

care.

Five Aims of Interventions

There are five aims of interventions in role-modeling the clients world. These are

standardized interventions, even though the intervention themselves are different.

These includes. (a) building a trusting relationship between the nurse and client, (b)
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promoting hope and positive self- esteem, (c) promoting the clients perception of

control, (d) assisting clients to identify and use their own strengths, and (e) setting goals

that have been mutually agreed upon by client and nurse that promote health and allow

the client to meet basic needs (Erickson, et al., 1983).

Nursing Process Date Collection Intervention

Patient observation, Building trust

Constant Positive Outlook
family and friends
Collaborative Independence
Medical care team Affirmation
Interactive Mutual Goals

Figure 2.0. The nursing processing using MRM (Erickson, et al., 1983).

MRM theory focuses nurses on an interactive and ongoing nursing process.

Figure 2.0 illustrates we integrate MRM in the nursing process. In order to interact

purposely and therapeutically with the patient, nurse has to internalize the standard of

care. The nursing process for MRM should be constant, collaborative and interactive.

The aim is to holistically approach and assess the patient and therefore they should be

the first option in date collection. Observation, is the physical data of which the nurse

can see through laboratories and physical assessment. Interaction with the patients

family and friends along with the verbal and non-verbal cues are also very significant in

data collection. The medical care team collaborative effort to plan patients care. MRM

focus on five standardized nursing intervention. Building trust with the initial focus of

nurses, next is to create or promote positive orientation to the patient and give then
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independence or control of their present situation. Another nursing goal of nurse is to

give patient affirmation to develop their strengths and lastly, we need to set mutually

directed goals to patients in order to achieve health and growth.

MRM give the nurses three main roles. They are facilitation, nurturance, and

unconditional acceptance. As a facilitator, the nurse helps the patient take steps toward

health, including providing necessary resources and information. As a nurturer, the

nurse provides care and comfort to the patient. In unconditional acceptance, the nurse

accepts each patient just as he or she is without any conditions

(http://www.mrmnursingtheory.org/definitions.html).

Conceptual Framework of the Study

Ericksons Modeling and Role Modeling Theory of Care

Patient with Bipolar I (depressive phase)

Modeling Phase
Assess the clients Model of World

Role Modeling Phase

Classify the clients Perceived needs according to his adoptive
Potential and implement the nursing strategies to assist patient achieve
equilibrium
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Statement of the Problem

This clinical paper aimed to utilize Helen Ericksons Modeling and Role Modeling

Theory in the care of a client diagnosed with Bipolar I disorder in Depressive Phase.

Furthermore, this clinical paper sought to answer the following queries;

Modeling

1. How does the client view her situation?

2. What were the clients adaptive potential with respect to

2.1. Arousal

2.2. Equilibrium

2.3. Impoverishment

3. What are the psychodynamics of the condition?

Role Modeling

4. What are the nursing strategies can be applied to assist the patient achieve

equilibrium through

4.1. Trust building

4.2. Positive outcome

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4.3. Independence

4.4. Affirmation

4.5. Mutual goal setting

Significance of the study

This study was conducted with the purpose that this will be significance to the following;

Patients with Bipolar Disorder. As the most important focus of the care and

attention they would receive that most comprehensive care they deserve. The

application of MRM, clients would be able to delineate a foundation for understanding

their present situation. This will also assist clients decide plans of action that are best for

them. Therefore, meeting a desired outcome that was initially build through mutual goal

setting and trust. The holistic care approach of the theory, can provided patients need

both their physical mental and spiritual needs. In this approach, patients will be able to

safeguard the wholeness and integrity for themselves that will eventually lead to

personal growth and achieve optimum health.

Family of Patients with Bipolar Disorder. As part of care, they have a vital role

in assisting the patient regain back their stable mental status. It is one of the intentions

of the study to educate them. Although, MRM allows the patient gain interdependence,

strong support system is also vital in giving the patient a stable stage of individuation to
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guide and direct the need of the patient to gain both independence and connectedness

with others all throughout life.

Mental Health and Psychiatric Nursing Service. This study would guide them

to assess specific aspects of the clients life, developmental and cognitive stages, basic

needs attainment, ability to adapt to stress, and affiliated- individuation are explored,

and all integrated into holistic nature of the client. These assessments enable the nurse

and client to plan interventions and set goals that can be evaluated at the of nurse-client

relationship. Therefore, providing effective nursing interventions for patients with bipolar

especially in their depressive phase.

Nursing educators. This would provide them holistic view of how MRM theory is

applied in the nursing practice. This study will guide the educators in providing a theory-

based nursing practice essential to educated future nurses to deliver a holistic care to

their clients. This study also explores the idea of encouraging learners to explore the

theory to become globally competitive nurses in the future.

Nursing Students. This study will guide them in becoming an effective and

efficient health care providers by MRM approach in caring patients with psychiatric

disorder. This theory will help them appreciate that each patient are unique. This will

guide them in giving patients holistic care approach in their related learning experience

and therefore become more compassionate and caring future nurses.

Nursing Research. This would allow them to become more involved in an in

depth study of patients with Bipolar disorder. This would also serve as a future
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reference for those researchers who wish to explore MRM theory in the field of

psychiatric nursing. This study aims to open the opportunity to develop current nursing

practice to effectively apply MRM theory in delivering holistic care to psychiatric nursing

especially with bipolar patients.

Community. As an indirect recipient of nursing care, this study would provide

awareness on the cause and management of patients with bipolar. This study would like

to eliminate social taboo in order to help patients with bipolar but they are accepted in

community. The community has to be aware that supporting and creating a non-

judgmental environment for patients with bipolar is essential in developing their strong

affiliated individuation.

Research Design

This research was qualitative case study. A case study is an in-depth

investigation of single entity or small number of entities, which can be an individual,

family, institution, community or other social unit. This method attempt to analyze and

understand issues that are important to the history, development, or circumstances of

the entity under study (Beck, 2010). This study typically determine the dynamics why an

individual thinks, behave, or develops in a particular manner and therefore, the nurse-

researcher was able to utilized this method to effectively apply the theory in focused.

Research Environment

This study was conducted at Maria Josefa Recio Therapeutic Center, Inc.

rehabilitation center offering comprehensive care program for recuperating mentally

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disturbed patients. Its clinically sound treatment and quality care reflect the shared

philosophy of the Hospitaller Sisters and the highly professional. Its aim is to give its

clients new life by reintegrating them to the main stream society.

The facility is located in secluded are in Talamban Cebu City, which is far from

the crown. Since, it is far from the city the facility provides quite atmosphere to their

clients, that can be therapeutic in having a sound mind. The facility is also surrounded

with plants and has a huge garden in the middle that can be give relaxing haven to the

guests.

The facility has a male and female ward in separate wing that could

accommodate 20 30 patients respectively. The center also has one observatory room

located in the left side wing of the center, one semi- private air conditioned room which

is located in the same wing. They provided ambulatory or outpatient services, which

caters for their day care guests that comes in at 8am and stays there until 5pm to

participate in therapeutic activities and interact with the inpatient guests. They also have

social service area where all recreational and therapeutic activities can be held. This

area is often utilized for the daily prayer with the sisters in the morning, followed by

morning exercises which is facilitated by the nurses and occupational therapist interns.

In the afternoon, the guests can watch movies or can have karaoke with the fellow

inpatients or day care guests. The center provides time schedule for their guests meal

and snacks and everybody should be taking their meals at the dining hall which is

located in the right wing of the center.

Research Instrument
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In obtaining a valid nursing health history from the subject the nurse has utilize

two major tools to obtain substantial amount of information for this study namely:

Biopsychological nursing assessment and Nursing Process Recording Form. The

nurse- researcher also made use of NANDA in making the nursing care plan for the

client. All, are filled up and modified by the nurse- researcher.

The first instrument that was utilized is the Biopsychologcial nursing assessment

through comprehensive interview using open and close ended questions with the

subject. This has allowed the nurse- researcher to collect data following guidelines for a

holistic psychiatric nursing assessment that was tailored to meet the specific needs of

the nurse, client and situation, this has also provided guidelines for conducting the

nursing interview to obtain data for a biopsychological history. The tool has 12 areas

which include the chief complaint, history of present illness, psychiatric history, alcohol

and substance use history, medical history, family history, developmental history, social

history, occupational/education history, culture, spirituality, and coping skills. Its used to

comprehensively assess the clients lifetime biologic, psychological, and social

functioning. The tool will assist the nurse- researcher in modeling and role modeling the

clients view of her situation (Obrien, 2013).

The second tool that was utilized by the nurse-researcher was the nursing

process recording, it is a written account of interaction between the nurse- researcher

and the subject. Process recording is used to analyze the nurse-client communication.

This tool, focuses verbal and nonverbal communication (Shives, 2008). It was modified

based on the assessment tool for MRM to assist the nurse-researcher in modeling and
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role modeling the clients world. This assessment tool has four components namely:

Description of the situation, expectations, resource potential and goals and life tasks.

The interview questions were based on this essential components and subcomponents

to enable the nurse- researcher assess the clients world and analyze data to role model

the clients world through MRM standardized nursing interventions.

The nurse researcher NANDA International (formerly the North American Nursing

Diagnosis Association), it is taxonomy of nursing diagnosis to guide the nurse-

researcher in designing the nursing care plans for the client. This will enable the nurse-

researcher to have accurate clinical intervention and diagnoses that is acceptable in the

nursing practice. Furthermore, this will guide the nurse- researcher to give nursing

diagnosis based on the comprehensive nursing assessment using the tools mentioned

above (www.NANDA.org).

Was there a nursing care plan? Add it here and describe.

The client is the primary source of the information; secondary sources are the

families and the significant others and the staff nurses in the facility, tertiary sources are

other health care providers. This case study is only limited to these sources.

Data Gathering Procedure

The nurse- researcher first presented the concept of the study to the panel of the

Graduate school for approval followed by the selection of the respective adviser. The

research then acquire a transmittal letter from the graduate school to the chosen

institution where the 50- hour practicum was conducted. The nurse researcher
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reported to the center administrator and the head nurse and the purpose of the

exposure. On the first day of practicum, January 31, 2017, the nurse- researcher was

oriented with the institutions facilities and patients.

The researcher chose a patient diagnosed with depression prior to the practicum

however, upon exposure the researcher have found out that most of the patients

admitted in the institution were diagnosed with Bipolar I either in their manic or

depressive phase. Among these patients, the research had chosen a patient in her

depressive phase with no psychotic features. The nurse- researcher then decided to

choose Miss K.T.B., among those clients to be the subject of this study and informed

her the purpose of this case study. Following this, is acquiring the patients previous

admission and hospital records to review patients history.

On the second day of practicum, the nurse- researcher has engage in the

patients daily routine and started to established rapport and trust with the client. Along

with this, the researchers has conducted group activities together with the other patients

to observe how the subject react to these kinds of activities. During interaction, the

researcher paid attention to how the client reacts and socialized with the other patients.

On the following day, patient has voluntarily opened up herself and thus the

nurse- researcher initiated the interview of the patients history of her illness. The

researcher listened closed to the patients history, perceptions, and misconceptions, at

the same time, conveyed empathy and understanding all throughout the interaction.

With the use of the tools, the nurse- research was able to extract pertinent information

required for this study.

 25

The nurse- researcher also interacted with the patients significant other

specifically her boyfriend and mother during their visit. The researcher has interacted

with the patient daily during the course of practicum (January 31 February 5, 2017)

immersing together with the subject and with other patients.

Chapter II
Results and Discussions

The purpose of this study was to explore the applicability of the MRM theory to a

person diagnosed with Bipolar disorder in depressive phase. The data gathered is

based on the assessment made by the nurse-researcher to identify how the client view

her world (modeling) and eventually role model the clients world to achieve the five

standardized nursing interventions towards the patients equilibrium. This chapter will

also discuss the psychodynamics of the patients current mental illness that will help us

identify how the client cope up with stress through APAM model.

Modeling: The Clients Worldview

Biopsychological History

Chief Complaint

This is a case of Miss K.B., 24 year old, single, residing at Bulacao Pardo Cebu

City with her mother and aunt was re-admitted for the 4 th time in MJRTC on December

10, 2016 due to suicidal acts and poor medicine compliance. She was noted to have

violent behavior, tendency to hurt self and others. Her mother and aunt accompanied

her to the psychiatric facility due to these bizarre behavior. She was noted to be restless

when she arrived at the facility.

 26

One week, prior to admission, the SO reported that Miss K.B. had not been

taking her medication and had tried to commit suicide. One day, prior to admission

guest became violent and has some episode of suicidal act. SO reported that she tried

to both kill herself and her mother.

Hours prior to admission, she had another episode of violence and hit her

mother. The nurse noted that around 5am, she was seen in the CR and stayed there for

hours. She was noted to be responsive however with some paranoia.

History of Present Illness

Miss K.B. was first admitted on March 09, 2013 at MJRTC due to homicidal and

suicidal thoughts with some violent behavior. Her symptoms started when she was in 3 rd

year college. In September 2012, she went to a psychological check- up and was given

maintenance drug. This was the time when her boyfriend had stopped communicating

with her. On January 2013, her mother stopped the medication since they thought she

was already well. In August of the same year, she had a violent encounter with her

board mates and had frightened other tenants thus she was brought to the barangay

hall where she resides and was given counsel and stayed calm. She had another

violent encounter on September 8 of the same year, with her cousin because of the

DVD player. She wanted borrow it however her cousin did not allow her to borrow the

thing so became outrageous, banged the door and drove the car carelessly. This has

prompted her mother to seek medical attention.

The second admission was on October 30, 2014, she was diagnosed to have

Bipolar I in her most recent manic episode. She was believed to be very stressed in
 27

school because she had a very tight schedule at school during that time. She was

violent and strong willed that led her mother to believed that she was into substance

abuse but the client has denied it.

The third admission was on September 27, 2016, she was admitted due to poor

medication compliance, she was in depressed mood, has some panic attacks,

hallucination and delusion and was aggravated due to the upcoming graduation. She

attempted to kill herself by taking muriatic acid. Aside from the symptoms above, she

also had insomnia, bizarre behavior, and anxiety. She was discharge on October 09,

2016

Psychiatric History

According to the patient, she does not know any of her relatives that was

diagnosed with the same mental illness. She said that the reason why they have

resulted to a psychological consultation was because of the advised for her college

guidance counselor. That was the time when she was not going to school because she

got heartbroken and depressed with her first boyfriend. She said that if it wasnt for that

she wouldnt be in the facility.

Alcohol and substance use history

The client has affirmed that she had substance abuse history. Although, she

admitted that she had had some drinking sessions with her friends but she could not

remember herself being intoxicated with alcohol. The client added that her mother was

so strict in making sure that she does not get herself intoxicated with alcohol. She

recalls, fighting with her mother because her mother thinks that she was alcoholic and a
 28

drug addict. She further narrated that she is fairly a good daughter and follows her

mother almost all the time.

Medical history

The client does not recall of any medical conditions that she had experienced.

She also added that she does not know if her mom has any present illness. She thinks

her mother is healthy. Her father died due to murder. She said that some of her relatives

had died due to cancer.

Family History

Miss K.B. is an only child, her father was murdered when she was still young

about high school. Her father was a prominent lawyer in their town in Badian while her

mother was a well-known school principal in their town and now working in a

government office of education in the region. She said that she was always pressured at

school when she was in elementary and high school because she doesnt want to

disappoint her mother. She believed that both of her parents are prominent in their town,

as well as her grandparents.

Development history

The client recalls that she was very close to her father. When she was a child or

during her elementary days when her father was still alive, they always talk and can tell

her father almost everything. She said that her father was very understanding thats why

she can open up with him easily than with her mother. Her mother was strict on the

other hand and was constantly pushing her to excel in academe thus she graduated in

elementary and high school with honors. She added that she didnt want her mother to
 29

get disappointed with her. Although, she considers her childhood experience to be very

tight with achieving high performance at school, this has made her more goal oriented

as she grows up, she wants to be on top of everything. Thats why she gets anxious if

does not get what she wants. She admits that she is a brat sometimes and strong

willed, that leads to miscommunication and fights with her mother. When her father died,

she became so sad and thought that has lost an ally. When her mother decided to live

together with her aunt (mothers sister), she thought she has lost her freedom. She said

that both of her mother and aunt are strict. She narrated some incident of running away

and/or escaping because her mother and aunt did not want her to go out at night with

her friends. She even recalled one time climbing the walls of their backyard because

she wanted to party with friends or go to an internet caf. She said that her mother and

aunt always make a sound decision when it comes to giving her punishment such as

grounding her for weeks or months either without going out or internet.

Social History

Miss K.B. engages in sports when she was still in elementary. She likes playing

soccer and was a member of a soccer team representing her college. She said soccer

was very therapeutic for her. She believes that when she is playing the sport, it gives

her an outlet to channel all her negative energy. She had very fond memories in playing

soccer. She added that in playing soccer she was able to travel places and met new

friends. However, her mother does not support this sports. She thinks her mother does

want her to play soccer.

The client also has no difficulty in making friends. She believes that she has got a

wide circle of friends because of soccer and some clubs she had joined when she was
 30

in high school and college. She also believe that this was due to school transfers. She

also had no difficulty in gaining friends when she started working. She believes that she

rarely gets herself into fights. She believes that whenever she gets into fight it was not

usually her fault or did not initiated it.

Occupational/Education History

Miss K.B as previously mentioned, was an academic achiever since elementary

due to familial background because of this she was able to enter the University of the

Philippines on her first year of college. During this time, she mentioned that the school

was very demanding. The paper works kept her awake during the night. She said that

she was shock with the environment and classmates because her classmates were very

vocal in terms of participating and getting good grades. She admitted that she was

really pressured.

When she stopped going to college and tried to work in a call center. Later, she

realized that finishing her studies was her top priority thus went back to college and

studied in the University of Cebu and then later on transferred to CTU. She transferred

because she was already mentally ill. She even made a letter to the dean to allow her to

graduate in spite of her being admitted in the psychiatric facility. She said she was really

eager to finish her college.

Culture

Miss K.B belongs to both Filipino decent. She grew up in family with a very

strong Filipino culture. She recalled that every time she visits her grandparents in their

town, they always family reunion and have big celebrations together.
 31

Spirituality

The client believes that her family has been founded with Catholicism she further

relate that it must be the reason why her mother and aunt was very conservative and

strict. She said she believes in GOD and has faith with HIM but not as much as her

mother and aunt. The client said my aunt is an old maid and never goes out with

friends. She also said that her mother and aunt was a member of religious

congregation. Miss K.B. even added that they wanted her to be like them but she

doesnt want to.

Coping Skills

The client believes that she gets frustrated because of her mother and aunt. She

thinks that nobody understands. Thats why she sometimes wants to die or perhaps to

marry early so she can finally live on her own or end everything. She also plays soccer

to release all her stress and frustration with her mother and aunt. She also seeks

comfort in her boyfriend and friends. When she was working, she thinks that she was

able to do what she wants and felt very independent however her mother made her

stopped and that made her feel sad. She also finds art comforting, she is fond of

coloring books and drawing or the arts. She said while doing this activity it makes her

think and reflect on things.

 32

Psychodynamics of the Clients Condition

INTERNAL EXTERNAL
STRESS STRESS
STRESS

STIMULATION OF LIMBIC SYSTEM

NEUROCHEMICAL ABNORMALITIES

LESS INCREASE INCREASE INCREASE DECREASED INCREASE DECREASE

NOREPINEPHIRINE SEROTININ NOREPINEPHIRINE DOPAMINE
GABA DOPAMINE SYNAPSES

BLOCK NEUROTRANSMITTERS
MANIC
DISORDER
DEPRESSIVE PHASE

EXCESSIVE SUICIDAL INSOMNIA/

SPENDING HALLUCINATION/
PROMISANITY INSOMNIA HYPERACTIVE THOUGHTS DYSEUPHORIA HYPERSONIA ILLUSION

BIPOLAR DISORDER

Figure 3.0. The pathophysiology of Bipolar Disorder.

 33

The case of Miss K.B diagnosed with bipolar disorder in her depressed phase.

The nurse researcher has developed the psychopathophysiology of the clients

condition as part of Modeling the clients world.

To begin with, Miss K.B. has acquired stress from stressful things that happen in

her life. It is noted that on the onset of her condition, she has experience emotional

stress due to the breakup with her first boyfriend. This was evidence by tardiness in

school and not performing academically thus prompted her to visit the school guidance

counselor. Miss K.B. was constantly, depressed during this time. Although, the patient

has no notable history of depression before this traumatic event, she has lost her father

in a tragic event in her early age. Since then, Miss K.B believes that her life has

changed. She further relates her relationship with her mother was too different from her

father. It is noted that her mother has restricted her in doing the things that keeps her

happy. Miss K.B being the only child was overly protected by her mother and coming

from a prominent family in their community she believes that she needed to excel

academically being her mother as the school principal in a public school. Therefore,

Miss K.B. has been constantly faced with pressure in meeting expectations.

The biochemical imbalances often create bipolar symptoms. Depression is a

disorder of motivation caused by chemical abnormalities in the brain systems containing

a class of transmitters known as monoamines. The specific monoamines implicated in

this biogenic amine theory of depression are norepinephrine, dopamine, and serotonin.

It is proposed that fluctuations in serotonin levels might be responsible for the wide

range of mood and activity states of manic- depressive illness. Neurochemical

abnormalities have been implicated as contributing factor to the development of bipolar

 34

disorder. Specifically, a paucity of the inhibitory neurotransmitter I-aminobutyric acid,

or GABA which is responsible for digression of neuronal stimulation, and elevated levels

of the neurotransmitters norepinephrine which is responsible for overall activities and

mood and dopamine which is responsible for fine movements and balance at the

synapses between neurons in the brains limbic system- which regulates mood and

emotions- have been implicated as facilitating the excessing transmission of neuronal

impulses resulting in a manic episode.

Meanwhile, inadequate levels of the neurotransmitters serotonin which is

responsible for sleep, heat, hunger and behavior, norepinephrine which is the chief

transmitter of sympathetic nervous systems and in dopamine have been identified as

hindering neuronal transmission resulting in a depressive episode.

Stressful life events can also act as triggers of bipolar disorder. The loss of her

father and breakup preceded her depression. It is suggested that these negative life

events predict bipolar depression. Additionally, low support from her mother has more

apt trigger to Miss K.Bs condition. Another factor is too much focus on goal attainment

can stimulate her onset of manic episode.

Assessment Tool Based on Modeling and Role- Modeling.

This assessment tool will guide the nurse- researcher in understanding the

clients perspective of the world. This is a way to collect and analyze data from which a

model of clients world is constructed. This tool will also guide in planning and

implementation of care based on the collected and analyzed data. The nurse research

will focused on the five aims standardized nursing intervention for this theory. The nurse
 35

process recording below is modified according to the four components of the

assessment tool to mobilize this theory.

Description of the Situation

While spending time talking and listening to Miss K.B., the nurse- researcher

asked the client to describe her current situation. She was also asked to share her

concerns about her present situation and what actions she believed would improve the

situation. With this information, the researcher could begin to understand the situation

from Miss K.Bs perspective and could start construct a model of the clients world,

which included identifying stressors that led to the present situation, as well as the

individuals therapeutic needs.

As a result of this conversation, the researcher has discovered that Miss K.B. has

a little knowledge of her mental illness. She doesnt seem to understand why she easily

feels depressed on certain situations. Through the exchange of ideas, the nurse-

researcher has identified several major stressors, which include (a) living with her

mother and aunt who are very strict and felt like they are running her life, (b) high

demanding situation such as school projects, (c) emotional stress such as heartaches,

(d) do not have enough knowledge of her mental disease. Miss K.B. has poor defense

mechanism and easily get depressed when faces in challenging situation. She is also

aware that she needs to comply with her medication in order to avoid depression. Miss

K.B. appeared to be worried that she might have caused other people emotional

distressed because of her current condition.

 36

Expectations

The nurse- researcher also asked Miss K.B about her immediate and long- term

expectation, and the responses has made the researcher understand how expectations

for the future affected her current thoughts and actions. The client has expected to get

better sooner or in time but she also expressed doubts on maintaining normal or stable

emotions. She states, ambot lang miss, hangtud kanuas- a ko ingon ani ang ginoo ra

ang maka hibaw ani.. Miss K.B thinks that she should develop a more stable coping

mechanism for her to over her mental illness. She further stated that she feels

exhausted with her situation I think I should be more strong and dili lang jud ko

magpalupig sa akong stress and sige ug think ug negative. Ambot lang miss usahay

kapoy man ug think.

Resource Potential

Member ko ug soccer team miss. I started playing when I was in UP. My mom doesnt

want me to play soccer. But thats the only activity where I can channel my negative

emotions. Naa koy daghan friends but I feel like Ive abandon them kay wala nako sila

gi-communicate for along time. Dili nako sila tubagon sa ilang message sa FB.

Sometimes, I lie them kung asa ko. I have a bestfriend, siya rasad usa akong giultian sa

tanan

Miss K.B. is uncertain on how to deal with her current situation with her mother

and aunt. She noted, that her mother hinders her mostly in doing things that will help

her become independent. Thus, this has led her to feeling hopeless and depression.
 37

However, her relationship with her boyfriend has given her resource availability, she

thinks that her boyfriend is the only person she can turn to whenever she feels down.

She also mentioned her best friend as the only person she turns to. The client lighted up

when she mention about playing soccer and how it can help her outlet her stress and

negativity as verbalized, thats the only activity where I can channel my negative

emotions. The client also expresses embarrassment of her mental illness, she stated

Naa koy daghan friends but I feel like Ive abandon them kay wala nako sila gi-

communicate for along time. Dili nako sila tubagon sa ilang message sa FB.

Sometimes, I lie them kung asa ko. The client believes that she has isolated herself to

her friends by avoiding them.

Goal and Life Tasks

Finally, the nurse- researcher inquired about Miss K.Bs immediate and future

goals. Miss K.B. stated that she would like to leave the psych facility as soon as

possible and return to work or her normal routine outside. She expressed her frustration

with her mother, by deciding to marry sooner so she would live with her mother

anymore. She also expressed her desire to go back to work as a call center agent

and/or able to practice her course which is psychology. Ganahan nako mu-uli miss, mu

work ko just like before. I hope my mom will listen to me. Sometimes maka think ko nga

mag minyo nalang kaha ko sah para di nako makapuyo sa akong mama? Mao na miss

akong goal. And ganahan sad ko mahimong doctor or maka practive sa akong course,

psychology. She further thinks that communication with her mother will resolve the

ongoing relationship issues between her mother and her. She is hopeful, that she will be

able to achieve her long term goal.

 38

Summary of findings in modeling the clients world

Clients identified needs/ stressors Clients coping potential/ adaptive

potential

Ineffective coping mechanism Equilibrium - Maladaptive

Knowledge deficit Arousal

Compromised family coping Impoverishment

After assessing the clients mode of the world through the use of APAM tool, the

nurse research has identified the clients perceived needs and stressors. Each

subsystems has enable the nurse assess and identify the adaptive potential of the

client. The identified clients need are: (a.) Ineffective coping mechanism, (b.) Knowledge

deficit, (c.) Compromised family coping.

The nurse researcher has discovered that the client has very little knowledge of

her mental illness that lead to non compliance of her medication. It is also identified

that the client has poor coping mechanism. Her inability to overcome emotional distress

and academic pressure led to maladaptive behavior. In addition, the client expressed

her inability to live independently. The client describes her mother as over protective

and strict. We can identify these stressor to be the clients arousal stage that has led her

to impoverishment state as the client was not able reach equilibrium. It is identified

during the interaction that the client has become hopeless and suicidal. In this case, the

client was not able to reach adaptive equilibrium and thus the client is now in her

impoverishment state.
 39

Role- Modeling

In role- modeling, individualized care is given to the client that is based in the

clients modeled world. The nurse will develop nursing strategies to assist the client

reach equilibrium.

In this section, the researcher presents nursing care plans based on the clients

Perceived needs achieved in the modeling phase. In each perceived needs there is a

corresponding findings on the modeling phase, scientific basis, goal and interventions

that integrates standardized intervention of the MRM theory, rationale, and the desired

adaptive outcome. This section will also discuss the overall implementation of the

nursing strategies and evaluation of the desired adaptive goals.

Role- Modeling 1: Ineffective coping mechanism

Clients perceived needs:

Ineffective coping mechanism related to multiple stressors repeated overtime

(e.g. academic pressure, loss of family member, failed relationship)

Findings on the Modeling Phase:

The client at an early age has lost her father. Miss K.B. thinks that her father is

her confidant and best friend. The client recalled his father as very close to her and is

the only person who understood her and supported her in everything she did. Miss K.B

further related that her life changed when her father died. Being the only child of

reputable parents had constantly reminded her to excel academically. The client,

believes that she should live up to her mothers expectations.

 40

When she reached adolescent, she experienced her first heart break and this

has led her to struggle emotionally that affected her academic performance and social

interaction. She was not able to continue her studies and abandon her friends.

What is the influence of academic pressure as viewed by the client?

Scientific Basis:

Stressors affect all areas of life and the client may have difficulty coping with

feelings and challenges in relation to relationships and individual tasks (Doenges,

2010). Why is there ineffective individual coping? What is the influence of long standing

stressor to the individuals coping mechanism?

Mutually agreed upon Goals:

Short term goals:

Within 2-3 days, the client will demonstrate or verbalized awareness of own

coping abilities and strengths. Additionally, the client will be able to identify ineffective

coping behaviors and its consequences. The client will also develop and use age-

appropriate, socially acceptable coping skills.

Nursing strategies/ interventions based on the MRM aims of interventions:

Nursing Intervention Rationale

Trust Building

Reassure client of safety and The therapeutic nurse- client

security by providing genuine relationship is built on trust.

positive regard and response to

client. Promote acceptance and

 41

honesty all throughout the nurse

client interactions.
Positive outcome/ orientation

Together with the client, identify Personal involvement of the

and develop coping skills in which clients provides a feeling of control

the client believes is appropriate in and increases positive outcome.

her situation. Assist patient in

verbalizing ineffective coping

mechanism and creating possible

solution to transform those

negative to positive coping

behaviors.
Independence

Encouraging independence in the Positive reinforcement enhances

personal responsibilities and in self esteem and encourage

decision- making related to own repetition of desirable behaviors.

self care.
Affirmation

Teach client to improve her level of If the client is more aware of

self awareness through critical herself, it is easier for her to

examination and reflection to utilized her resources and she will

assist her in mobilizing her inner also develop her self confidence

strengths. and reduce her self doubt

therefore leading to locus control.

 42

Role- Modeling 2: Knowledge deficit

Clients Perceived Needs:

Deficient knowledge related to unfamiliarity with information sources and

treatment regimen.

Findings on the Modeling Phase:

During the modeling phase, the nurse researcher have identified that the client

only had limited knowledge of her mental illness especially the significance of adhering

to the treatment regimen. Her mother has verbalized that they discontinued the clients

medication since Miss K.B. looks okay. When the nurse researcher reviewed the

clients medical records, it was found out that her readmission was primarily due to

symptoms relapse related to non-compliance of medication. Miss K.B. also further

verbalized that the reason why she got diagnosed was because of her guidance

counselor who referred her to the psychiatrist, siya jud and naka- ingon aning tanan

miss.

Scientific Basis:

Lack of knowledge or misinformation of the disease process and treatment plan

may lead to negative outcome and increase stress level. The client needs to be aware

of the activities that reduces the risks, signs and symptoms, treatment plan and

reinforce positive outcome (Doenges, 2010).

Mutually agreed upon Goals:

 43

Within 1-2 days of nursing intervention, client and family will verbalized

understanding about the disease process and treatment regimen. The client will also be

able to verbalize the importance of adhering to the treatment regimen and identify the

possible adverse effect noncompliance of her medication.

Nursing strategies/ interventions based on the MRM aims of interventions:

Nursing Intervention Rationale

Trust Building

Assess clients level of knowledge An adequate database is

regarding effects on psychological necessary for the development of

problem on the body and the an effective teaching plan.

treatment regimen as well as its
adverse effect.
Explore feelings and fears held by
Verbalization of feelings in a
nonthreatening environment may
help client come to terms with long

client. These feelings may have unresolved issues.

been suppressed or repressed for

a very long time and their

disclosure will be a painful

disclosure. Be supportive

Positive Outcome/ Orientation

Explain assertiveness technique to Use of these techniques enhances

the client. Discuss the importance self- awareness and facilitate

of recognizing symptoms clients interpersonal relationships.

especially during aggressive This will also build strong affiliation

behaviors and suicidal/ thoughts with others.

 44

Discuss adaptive methods of These technique may be

stress management and develop employed in an attempt to receive

technique on making sure stress or anxiety. This will also

medications is religiously taken. keep the client know the

importance of regularly taking

medication.
Independence

Discuss the importance of The will encourage client to

medication compliance and perform and independently take

develop task that could gradually medication, without being

decrease the amount of assistance reminded that its time to take

given in taking medication. medication.

Set a structured plan or schedule Setting a structure mediation

of medication intake. schedule intake will ensure

compliance.
Affirmation

Establish a system of reward for Positive and negative

compliance with therapy and reinforcements contribute to desire

consequence for noncompliance. and change behavior.

Ensure that the rewards and

consequence are concepts of

value to client.

Role Modeling 3: Compromised family coping

Clients Perceived Needs:

 45

Compromised family coping related to little support to client and unrealistic

expectations of each other.

Findings on the Modeling Phase:

Miss K.B. is an only child of a lawyer and a teacher. Her mother used to be a

principal in one of the public schools in their community and now working at the

department of education. The clients father was a well-known lawyer in their community

and has an untimely death when Miss K.B. was in grade school. The client related that

when her father died everything has changed. Miss K.B. also shared that when she

was still in grade school, she always feels that she has to perform academically

because her mother was a school principal. The client added, that she does not want to

disappoint her mother. When she went to college and they moved to her aunt, she

related that her mother and aunt has restricted her in going out. Miss K.B thinks her

mother does not understand her, dili man kasabot akong mom nako miss, usahay kay

mu ikyas nalang ko para maka gawas, I feel like a prisoner, akong mom ug aunt kay

strict kau (my mother understand me, sometimes I escape so I can go out. I feel like a

prisoner, my mom and aunt are very strict.

Scientific Basis:

As defined compromised family coping is a situation in which family member is

providing insufficient support, comfort or assistance or encouragement that maybe

needed by the client to overcome or manage stress. (Doenges, 2010).

Mutually agreed upon Goals:

 46

Within 1-2 days of nursing intervention, both the client and family member will

identify resources within themselves to deal with the situation. They will also be able to

express more realistic understanding and expectation with each other and provide

opportunity for the client to deal with the situation on her own.

Nursing strategies/ interventions based on the MRM aims of interventions:

Nursing Intervention Rationale

Trust Building

Established rapport and May assist family to accept what is

acknowledge difficulty of the happening and be willing to share

situation problems.
Determine current knowledge and Lack of information or unrealistic

perception of the situation perceptions can interfere with

family members and clients

response.
Positive Outcome

Discuss underlying reasons for When family members know client

client behavior with the family. is behaving in different ways, it

Involve SO in information giving
helps them understand and accept
and identifying solutions.
Reframe negative expression into or deal with situation.
Involvement in care enhances
positive whenever possible.
feeling of control and self- worth

for both parties.

This will modify attitudes towards

each other and therefore may look

at the future positively.

Independence
 47

Encourage client and SO to This will facilitate the use of

verbalized strategies on how to desired behavior when they are

resolve issues or conflicts when faces in stressful situation.

the situation arises

Affirmation

Teach effective communication This will enhance more affirmative

technique to both client and SO to communication to both client and

avoid making judgment statement SO and therefore having much

and miscommunication harmonious relationship.

Implementation

During this phase, the nurse researches establish trusting relationship to the

client by spending more time with her. The nurse researcher knew that rapport has been

established because the client has gradually open herself and related her story. Miss

K.B. was asked to share about her situation. The nurse researcher has made sure

therapeutic communication was utilize althroughout the conversation. Furthermore, the

nurse researcher maintained non judgmental environment through maintaining eye

contact and listening attentively.

As identified in the rode- modeling phase there are perceived needs that should

be addressed which included, (a.) Ineffective coping mechanism, (b.) knowledge deficit,

(c.) compromised family coping. In order to achieve and meet the knowledge deficit

needs the nurse- researcher has conducted health teachings focusing on the clients

disease process. The nurse researcher also has made given much importance in
 48

effects and mechanic of actions of the clients medication and the importance of

compliance to the medication.

To address the ineffective coping mechanism and compromised family coping, a

group therapy through open forum was utilized. This has enabled the nurse researcher

identify the issues in both side and address it though counseling. At this point, the

clients strengths and weaknesses has been outlined. Through this, the nurse

researcher has introduced technique on how to manage stress through further health

teachings and sharing personal experiences. In this sense also, trust is built which is

one of the aims of interventions for the focused theory.

Reinforcement of Miss K.Bs resource potential, the nurse researcher has

encourage to play soccer in the afternoon. Since, this is the only activity that she is

comfortable doing whenever she stressed. This has also helped boost clients self

confidence. The nurse researcher also conducted parlor games and encourage the

patient to participate in order to have fun This will also encourage the client to gain

friends and interact with the other clients in the facility.

Evaluation

After 2-3 days of nursing intervention both the client and the SO has verbalized

understanding of the clients mental illness and most importantly, both have identified

and verbalized the essential factor of medication compliance for the client to achieve

recovery. The client has showed compliance by following the schedule of timing for

medication intake. The client has also verbalized that she will make a time schedule for

her medication upon discharge so she cant skip it. The SO and the client have also
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identified some of the adverse effect and the possible relapse if medication has not

been taken religiously and as prescribe. Both of the SO and the client also ahs identified

notable signs and symptoms that the client might experience in manic or depressive

episode.

Techniques on stress management was also gradually practice such as coloring

books, playing soccer, and participating in group activities in the facility. Although, the

nurse researcher cannot fully evaluate the outcome for the clients enhanced coping

mechanism the client has showed gradual progress in managing stress. Miss K.B. also

has admitted that sometimes she cant control her emotion. She also has mentioned

that playing soccer relieves her stress and divert her negative thoughts to positive.

The ongoing issue between the mothers overprotectiveness and the clients eagerness

to be independent has not be fully addresses. The mother is quite worried that if Miss

K.B will go out she might go back to her previous state. She wants to make sure that the

client will be fully recovered with her mental illness before deciding to let her become

more independent. The SO has showed support in the clients desire to play the sports

she likes. Also allowing her to be visited by her boyfriend. The mother thinks the

boyfriend of her daughter is patient and kind.

Synthesis

Clients perceived needs were examined through evaluation of adaptive potential.

The critical equilibrium of the clients adaptation exists was enhanced through strategies

that were aimed at strengthening adaptation and building new coping resources.
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