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PSYCHIATRIC PATIENT ASSESSMENT
INDIVIDUAL CASE STUDY
STUDENT: ERNESTO S. MALAMION III DATE: SEPTEMBER 29, 2012
PATIENT: N.D. AGE: 40 YEARS OLD
HISTORY
1. Chief Complaint (Patients Statement put into quotes) The
patient states that hindi kasi ako makatulog dahil sa kaiisip sa
nangyari sa akin and
was supported by the chart.
2. Present Symptoms Body odor
3.
Admission date and reason for admission She was admitted last
September 05, 2012 with an admitting diagnosis of Bipolar
disorderwith psychotic symptoms. She was admitted because she could
not sleep. She went toNCMH alone.
4. History of Present Illness (onset of problems; duration of
problems; psychological symptoms) Patient report that she could not
sleep for this past few weeks because she could not stop
thinking about her son and separates husband. She also states
that she goes back inNCMH because she didnt follow the instructions
of her doctor when she went out of NCMHon her last confinement.
5. Health History (Including past psychiatric hospitalization
when/where; history of counseling) Her first confinement in NCMH
was on March of this year and was discharged but was
followed on July of the same year but discharged again. Her last
confinement as of thepresent was on September 05 of this year. All
of her confinement was at the NationalCenter for Mental Health.
6. Family History The patients father was already dead while her
mother was alive. She has 4 siblings. There
was no family history of mental illness.7. Personal History
(married, divorced, single)
The patient was married but separated and with 1 son.MENTAL
STATUS EXAMINATION
1. General Behavior, Appearance, and Attitude (dress, grooming,
posture, attitude toward theinterviewer) A 40 year old woman with
black hair, appropriately dressed with hospital uniform. She
appeared to be bathe already and properly groomed. She has a
positive attitude toward hernurse and others. Her behavior seems to
be like a normal person. She always crosses herlegs during NPI.
2. Eye Contact The patient was able to maintain eye contact
during nurse patient interaction. Eye
movement was stable and displays interest on the
interaction.
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3. Speech
The patient spontaneously speaks out her thoughts and feeling
during the NPI. She speaks in a medium loudness and there is no
need for repetition and clarification of
questions.
4.
Affect Her affect is well appropriate with her thoughts. She did
not show boredom. She feelshappy during every meeting.
5. Mood She has a stable mood during every meeting. She complies
with hospital policies and
shows no interest in escaping the premises.6. Thought
a) Process (Rate and flow of ideas i.e. loose associations,
flight of ideas, tangentiality) Patient has a continuous flow of
ideas. She was able to recall past events and was
able to retrieve recent memories. Her experiences in life
predominated although it wasmoderately difficult to established a
discussion pertaining specific event in her life.
b)
Content (i.e. Delusions, ideas of reference, obsessions,
preoccupations, suicidal ideations) None7. Perceptual
Disturbances
The patient denied illusions and hallucinations in all
modalities. She also claimed that couldalready sleep at night
without thinking anything.
8. General Intellectual Level The patient was an under graduate
of high school but was able to think and understand
abstract things. There was no flight of ideas or looseness of
association. She was able toanswer questions appropriately without
hesitation.
9. Judgment She could judge someone or something based on what
she sees or heard and can
rationalized her judgment. She has a good thinking ability.10.
Insight Evaluation (Understanding of Illness and Evaluation)
The patient showed partial insight about her condition. She
admitted that she has a mentalillness and is willing to follow all
of the doctors orde r to become mentally healthy again. Shehas
knowledge on the reason of her admission but was limited to the
symptoms she felt.
SUMMARY:
Patient N.D., a 40 year old woman was admitted on September 05,
2012 due to difficulty ofsleeping. This was her 3 confinement since
her first on March of the same year. She was diagnose withBipolar
Disorder with Psychotic symptoms. The patient has no family history
of mental illness. She has oneson and a husband but separated. Her
3 confinement is at the National Center for Mental Health. It
lookslike she displays a normal behavior compared to the other
patients although her mental ability seems to beslightly lower in
proportion to her age.
NURSING DIAGNOSES: (Based on Present Symptoms)
Imbalance Nutrition: Less than body requirement related to poor
eating habits as evidenced by lackof appetite.
Self care deficit related to hygiene as evidence by body
odor.
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CHOSEN DIAGNOSIS:
Self care deficit related to hygiene as evidence by body
odor.SHORT TERM GOAL WITH INTERVENTIONS:
After 3 days of nursing intervention, the patient shall be able
to irradicate her body odor. Teach patient about good hygiene
practices to irradicate body odor. Provide hygiene kit to be used
by the patient such as soap, shampoo, and toothbrush with
tooth paste. Give instructions to the patient regarding her
hygiene. Evaluate the hygiene of the patient.
LONG TERM GOAL:
After a month of nursing intervention, the patient shall be able
to maintain good personal hygiene.
