General Objectives: The student nurses will be able to create a Case Presentation and seek to
develop their knowledge, skills, and attitude through working on this training, and be able to
appreciate the importance of teamwork and working under a directory.
SPECIFIC OBJECTIVES:
After 1 to 2 hours of case presentation, the student nurses must have:
I. Knowledge:
● Understanding about the pathophysiology and etiology of the case being presented.
● Knowledge of the roles of drug therapy in managing the client related to the patient’s
diagnosis.
● Recognize the contributing factors associated with the development of the diagnosis.
● Know the rationale behind every intervention given for the care of the patient and the
nursing responsibilities associated.
● Demonstrate knowledge in identifying nursing problems and categorizing them
according to the client’s needs.
II. Skills:
● Systematically present the data pertinent to the case being gathered.
● Formulate and implement a suitable nursing care plan that will help for the patient’s case.
● Give important health teachings and assist the patient in the performance of activities of
daily living whenever needed.
● Comply with the associated nursing responsibilities, precautionary and preventive
measures are providing care to the patient.
● Reassess patients to determine whether a re-modification of care plan is necessary.
● Put into action the skills that we have learned in RLE into real life situation in handling
the patient such as:
1.) Taking Vital Signs
2.) Checking and Giving Oral Medications as ordered
3.) Applying appropriate Nurse-Patient Interaction
● Gain the confidence in handling such cases in future.
III. Attitude:
● To be honest and truthful in following the policies and guidelines.
● To have a sense of responsibility and initiative in accomplishing the assigned tasks.
● To work harmoniously with others and become a team-player.
● To demonstrate tolerance and patience all throughout.
● To have a positive attitude towards criticisms and suggestions.
1. General Information:
Name: Patient S.P
Age: 21 years old
Sex: Female
Birth date: June 09, 2001
Nationality: Dual Citizenship
Date and time of admission: December 21, 2021 / 10:30 AM
2. Sources of Data:
Primary Source: Patient S.P. herself and Patient’s Chart
Secondary Source: Admitting Diagnosis: Bipolar Affective Disorder Current Episode Manic with Psychotic
Symptoms
3. Patient History:
3.1 Socio-economic, Environmental and Cultural Factors
Patient S.P. was adopted when she was a child and according to patient S.P. her adoptive parents
treated her like she was their own daughter. She had her nanny and driver during her childhood
and was treated like a princess but unfortunately she was sexually abused by her driver. Patient
S.P. lived with her boyfriend, which is now her ex-boyfriend, for one and a half years and that
being said, she conceived a child and gave birth to a baby boy. While she was pregnant they
lived in the house of her ex-boyfriend’s family wherein she experienced all the hardships she
never felt when she was living with her adoptive parents. Her past live-in partner was a drug user
which even reached to the point of forcing her to use prohibited drugs as well.
3.2 Nutritional Status
Patient S.P. has no signs of any constant physical illness, she’s physically active and but cannot
fully performed her daily activities. She is undergoing a not-so-strict and self-made diet due to
her slight weight gain.
3.3 Past Health History
-
3.4 Family Health History
-
3.5 History of Psychiatric Illness
4. Past Psychiatric History
Due to her childhood trauma, influence of her ex-boyfriend of using prohibited drugs, and the
effects of the said drugs, patient S.P. started to experience psychotic symptoms: one of those was
difficult to identify the reality. Those symptoms have progressed and because of that, in the year
2020 patient S.P. was admitted to her first Psychiatric Facility diagnosed with Bipolar Disorder.
5. Present Psychiatric History
2021-Present, patient S.P. was admitted to St. Lucy Caregiving Services last December 2021
because of lack of self-care, and emotional disruption. The client is noted with labile affect and
exhibits psychotic symptoms. The client displays + auditory hallucinations, + tangentiality, +
circumstantiality. The client is noted with blunt affect but is able to make eye contact from time
to time. The client appears to have some bruises around her arms and thigh. The client also tested
positive for amphetamines compounds.
6. Mental Status Exam 1
1.
General Appearance and Motor Behavior:
The client has bruises on her arms and thigh; she also has tattoos on several parts of her
body. The client is noted with a blunt affect and has bizarre make-up. The client displays
agitation and restlessness.
2.
Speech and Communication
The client tends to be loquacious.
3.
Mood and Affect:
Client S.P. was anxious and noted with labile affect.
4.
Thought Process and Content:
The client exhibits + tangentially, + circumstantiality and + auditory hallucinations.
Student Nurse
Therapeutic
Patient
Communication
Defense
Mechanism
Used
Hi po Ma’am. I am Student Nurse
Rosaly but you can call me Aly from
Giving
Hi Aly I’m S.P, 21 years old. I
Giving
Recognition
already have a baby boy. I am
Information
Phinma Araullo University. May I
almost 2 years at this facility.
know your name and other
information about you that you can
share with me?
Ma’am S.P I will be your student
Formulating
nurse for four days, hoping you and I
Contract and
will have smooth days ahead. We will
explaining
be here starting today until April 20.
Ohh. Me too.
termination at the
end of duty/shift.
Hello Ma'am S.P! Natatandaan nyo pa
Exploring
po ba kung anong pangalan ko?
Oo, naman ikaw ang aking
Student Nurse, Rosaly pa nga
yung full name ng Aly eh.
Ma’am S.P can you tell me a story
about yourself?
(Nodding)
Exploring
Sure. Pero tagalog ko nalang
ikwento ha.
Active Listening So yun nga one time naman
napansin akong mga staff na
parang ini’slap ko yung
buttocks ko then hindi ko
naman alam na irereport nila
yun sa Doctor ko and nalaman
ko na lang nung nagkaroon na
kami ng session uli.
Noong napansin ng mga staff yung
Exploring
Nung time na yun akala kasi
ginagawa mong pagslap sa buttocks
nila sinasaktan ko yung sarili ko
mo anong naging realizations mo
dahil pinapalo palo or na'slap
noong kinausap ka ng doctor mo about
ko yung sa buttocks ko pero
doon?
pinaliwanag ko naman yun na
Sublimation
yung time na yun parang naiisip
ko na ang taba na pala ng mga
hita ko at hindi na sya maganda
so instead na ulitin ko yung pag
slap ang ginawa ko na lang
idinaan ko sa pag zuzumba
namin every morning ang
naiisip ko para din way sya na
mabawasan ang timbang ko at
lumiit na uli yung mga
pwedeng lumiit.
Good morning po ma’am S.P. ano
pong gusto ninyong pag-usapan
ngayong araw?
Giving Broad
Ahmm. Ano nga ba? Hmmm.
Opening
(Silence)
Using Silence
Pasensya ka na ha wala ako sa
Reaction
mood pa eh may nangyari kasi
Formation
kanina ang aga aga.
I understand po ma’am. Tell me your
concern about what happened earlier.
Providing Leads to Kaninang umaga kasi gagawin
the Patient
Sublimation
ko na sana yung morning
routine ko and naayos ko na
kagabi ang mga toiletries ko
pero kanina paglapit ko doon
gulo-gulo na yung ibang gamit
like yung suklay ko and nakita
ko din si A. kanina na ginamit
niya yung suklay ko ng hindi
man lang nagpaalam sa akin
kaya ayon sa inis ko bumalik na
lang muna ako sa higaan ko at
duon ko binuhos ang inis ko.
Maari mo bang sabihin sa akin kung
ano ang iyong ginawa pagkatapos
Exploring
Imbes na magalit ako kinausap
ko sya ng mahinahon at
mong malaman na ginamit ni Sir A
ipinaintindi sa kanya na
ang iyong suklay ng walang paalam?
kailangan nyang magpaalam sa
may-ari ng kahit na anumang
bagay na naisin nyang gamitin.
Maganda yung ginawa mong
pagkausap kay Sir A. dahil mas
maintindihan na niya kung bakit ka
nagalit at mas mauunawaan na niya na
kailangan pa ring magpaalam pag
gumamit ng gamit ng iba kahit gaano
Giving
Kasi tama din yung kasabihan
Recognition
na gawin mo sa iba yung gusto
mong gawin nila sa iyo para
wala kang nakakagalit at isa pa
hindi naman ako madimot eh.
Sublimation
pa kayo ka-close.
Good morning ma’am S.P. Ito na po
Exploring
Hmm. May ginawa akong sulat
ang huling araw namin dito sa facility.
kagabi bago ako matulog dahil
May mga gusto ka pa po bang ibahagi
sa mga napag-usapan natin
sa akin?
nung mga nakaraang araw. dahil
Rationalization
din sa iyo mas naging open ako
sa sarili ko dahil mas tanggap
ko na yung nagawa kong
pagkakamali nuon na mas gusto
ko nalang kalimutan dati. Pero
dahil sa pakikinig mo napagisipan ko na gagawin ko nalang
lesson yung mga nangyari sa
akin at para maging okay na din
ako ng tuluyan at ng makita ko
na yung anak ko sa labas at para
din makasama ko na yung
family ko.
Nakaka tuwa na nakatulong ang
Acknowledgement Masaya din ako kinakausap ka
pakikinig ko upang mapabuti ang
at thank you sa pakikinig. Pero
iyong nararamdaman.
syempre minsan nalulungkot pa
din ako kasi namimiss ko yung
family ko sa labas at yung anak
ko.
Maari mo bang sabihin sa akin kung
Exploring
Madalas binubuhos ko sa pag
anong mga bagay ang ginagawa mo sa
sasayaw sa umaga o kaya
tuwing nalulungkot ka ?
naman kapag sa gabi ako naka
ramdam ng lungkot iniiyak ko
nalang.
Kamusta naman ang pakiramdam mo
ngayon?
Exploring
Okay naman ngayon masaya
ako na malungkot kasi aalis na
Sublimation
kayo.
Masaya din ako na nalulungkot gaya
Giving
mo nakakalungkot na aalis na kami
Recognition/
Thank you din!
pero masaya ako kasi marami akong Acknowledgement
natutunan dito sa facility at sa
pakikipag-usap sa iyo.
Student Nurse: Maari mo bang sabihin sa akin kung ano ang iyong ginawa pagkatapos mong
malaman na ginamit ni Sir A ang iyong suklay ng walang paalam?
Client: Imbes na magalit ako kinausap ko sya ng mahinahon at ipinaintindi sa kanya na
kailangan nyang magpaalam sa may-ari ng kahit na anumang bagay na naisin nyang gamitin.
Analysis: The client chooses to suppress her anger through other patients to have better
communication with the other patient.
Student Nurse: Maari mo bang sabihin sa akin kung anong mga bagay ang ginagawa mo sa
tuwing nalulungkot ka ?
Client: Madalas binubuhos ko sa pag sasayaw sa umaga o kaya naman kapag sa gabi ako naka
ramdam ng lungkot iniiyak ko nalang.
Analysis: The client chooses to channel or divert her frustration into dancing and crying at night.
Assessment
Nurse:
Client:
Analysis:
5.
AbstractThinking:
StudentNurse:
Client:
for
Self-harm
or
Suicide
Analysis:
6.
The
client
has
poor
abstract
thinking.
Memory:
Recent Memory:
Student Nurse: Good afternoon ma’am S.P. anong snack ang pinili mo this afternoon?
Client: Hi Aly, yung coffee flavored cookie yung pinili ko kasi mahilig ako sa kape hehe.
Analysis: The client has good recent memory as she was able to remember what she had
during her snack in the afternoon.
Remote Memory:
Student Nurse: Hello Ma'am S.P! Natatandaan nyo pa po ba yung pangalan ng mommy
mo?
Client: Oo, naman si Mommy Rosalinda Pineda.
Analysis: The client has good remote memory as she remembers her mother’s name.
7.
Intelligence:
Student Nurse: Habang nandito ka sa facility anong pinaka-narealize mo?
Client: Yung sa mistakes ko na dapat hindi ko na siya ulitin pa para mas maging better
akong tao at mother sa baby ko.
Analysis: The client has a good intellectual response as she was able to answer the
question provided to her.
8.
Concentration:
Student Nurse: Hi ma’am S.P natatandaan nyo pa po ba yung date ng pagpasok nyo dito?
Client: Oo naman yun ang date na hindi ko makakalimutan.
Analysis: The client has good concentration as she was able to recall her date of
admission
.
9.
Orientation:
Orientation to Person:
Student Nurse: Hello Ma'am S.P! Natatandaan nyo pa po ba kung anong pangalan ko?
Client: Oo, naman ikaw ang aking Student Nurse, Rosaly pa nga yung fullname ng Aly eh.
Analysis: The client was oriented to the person as she was able to remember her student Nurse.
Orientation to Place:
Student Nurse: Ma'am S.P. maari nyo po bang sabihin sa akin kung nasaan kayo ngayong araw?
Client: Nasa St. Lucy Caregiving Services ako.
Analysis: The client was oriented to place as she was able to tell where she was.
Orientation to Date:
Student Nurse: Alam mo ba kung anong date ngayon?
Client: Of course, today ay Tuesday, April 18, 2023
Analysis: The client was oriented to date.
10.
Judgment:
Student Nurse: Noong napansin ng mga staff yung ginagawa mong pagslap sa buttocks mo
anong naging realizations mo nung kinausap ka ng doctor mo about dun?
Client: Nung time na yun akala kasi nila sinasaktan ko yung sarili ko dahil pinapalo palo or
na'slap ko yung sa buttocks ko pero pinaliwanag ko naman yun na yung time na yun parang
naiisip ko na ang taba na pala ng mga hita ko at hindi na sya maganda so instead na ulitin ko
yung pag slap ang ginawa ko na lang idinaan ko sa pag zuzumba namin every morning ang
naiisip ko para din way sya na mabawasan ang timbang ko at lumiit na ulit yung mga pwedeng
lumiit.
Analysis: The client has good judgment as she was able to find ways to resolve her current issue.
11. Insights:
Student Nurse: Ma’am S.P. pwede mo bang sabihin sa akin kung anong dahilan ng iyong
pagpasok dito sa facility?
Client: Oo, kasi meron akong Bipolar Disorder. Aware naman na ako sa sakit ko kasi
minsan naglelecture din si ma’am Lucy sa amin tungkol sa mga sakit namin.
Analysis: Client has good insight. She is aware of the disorder she has.
12. Psychopathology
Study Base: Multi-factorial model of bipolar disorders.
Patient’s Base:
Early Trauma
Environmental
& Social
Factors
Drug Abuse
Stressful Life
Events
BIPOLAR
DISORDER
Manic Episode
High level of
Noradrenaline
Neurotransmitters
Imbalances
High level of
Dopamine
High level of
Serotonin
Outcome
+ Auditory Hallucinations
+ Tangentiality………......
+ Circumstantiality………
+ Labile Affect……….....
+ Anxious……….............
13. Drug Study
Divalproex Na 500mg BID (8am & 6pm)
Nozinan 100mg (1/2 tab once a day leef sleeping)
14. Nursing Care Plan
15. Discharge Planning
Discharge planning should be done with multiple aims in mind, the major one being:
● Assisting with re-entry the community
● Providing the support needed to sustain progress that was achieved during the in-patient
care
● Minimizing the chances of relapse or immediate return to the mental health establishment
● Preventing homelessness, suicide and/or being criminalized
● Ensuring early intervention during crisis and relapse
● Optimal health and well-being of the patient.
For the discharge planning to be effective, an assessment of the specific needs of that particular
patient should be first performed. Some domains that need attention during the assessment
include:
● Capacity for self-care: Assess the patient’s capacity, insight, and perception toward the
psychiatric illness.
● Clinical needs: Identify the potential predisposing factors that can lead to distress or
relapse. The patient should be informed about the importance of sleep, hygiene, nutrition,
lifestyle modification, anticipated adverse effects of the medication, and duration of
treatment.
● Other needs: Assess domains such as socioeconomic, cultural, and spiritual. Discuss
where the patient would stay after the discharge: the levels of support available and
needed, the wishes and decisions of the patient and the family, and the recommendations
if any the treating team has in this regard should be taken into account, and a consensus
arrived at through discussions between relevant parties.
It is essential to keep the patient’s family in the loop. The patient’s progress during the MHE
stay and how ready the patient is for discharge should be periodically discussed with the
family. According to Perreault M, Tardif H, Provencher H, Paquin G, Desmarais J, Pawliuk
N, et al. (2005), satisfaction in discharge planning drops when there is no contact between
staff and the family regarding discharge.
DISCHARGE STATUS AND INSTRUCTIONS
Final Exam, Interval History
● S.P. is stable. No psychiatric complaints are expressed. Symptoms of a Bipolar Affective
Disorder are not reported today.
● Medication has been regularly taken and behavior has been stable and unremarkable. She
describes no side effects and none are in evidence.
Final Exam, Mental Status Exam
● S.P. is calm, friendly, attentive, casually groomed, and relaxed. She exhibits speech that
is normal in rate, volume, and articulation and is coherent and spontaneous. Language
skills are intact. Mood is entirely normal with no signs of depression or mood elevation.
Affect is appropriate, full range, and congruent with mood. Insight into illness is normal.
Social judgment is intact. There are no signs of anxiety. There are no signs of hyperactive
or attentional difficulties.
Type of Discharge: Regular
Condition on Discharge: Greatly improved
Prognosis: Excellent
Medications at Discharge:
Divalproex Na 500mg (BID 8am & 6pm)
Nozinan 100mg (1/2 tab once a day leef sleeping)
Medication Instructions: Patient should continue with current medications and follow-up with
her primary care provider.
Consent: Patient was advised regarding the risks and benefits of treatment.
Physical Activity: No limitations on physical activity
Dietary Instructions: Regular diet.
Other Instructions: The patient was advised to call a treating physician if symptoms recur.