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Psychiatric History/Developmental History The patient is born via NSVD (normal spontaneous vaginal delivery), no known complications and abortion attempts of the mother. According to the patient he was both breastfed and bottlefed up to 1 ½ years of age. He was also toilet trained by his parents. He further claimed that he was pampered by his parents with love and affection as well as with other things like toys, books and clothing. Basically, he had a good childhood experience as claimed. During his school age, he remembered that he does not participate in school activities and seldom mingle with his classmates. He further claimed that he is respectful to elders especially to his parents and grandparents. During his high school years, he experienced being involved with fist fights with the bullies. He remembered he was never separated from his family and was able to finish his degree in mechanical engineering. He was married at the age of 36 years old. After how many years, his wife gave birth to a baby boy. They then decided that the husband will go abroad in Saudi Arabia and work as a mechanical Engineer while his wife is left with the son in the Philippines. After how many years, they decided to switch, the husband was left with the baby and his wife went abroad to Saudi to work as a nurse at a hospital. With this set up of a long distance relationship which is too hard to handle. Being away from your wife and being with your son for several years. His wife has only quality time for them whenever she comes home for vacation. Whenever his wife comes home for a vacation, he is usually very happy.
It was during this time that he knew that his sister died to an accident. mood swings. he claimed that he was shy. illusions. Often times he sits on his bed or lie down and sleep. Now at his age of 56 years old. The son saw his change of reactions and behaviors 5 days prior to admission like auditory hallucinations. That is the time he feels very sad because he claimed that he was really close to his sister. For his other siblings. 2. he visits them occasionally and whenever there was a problem with one of the member of the family he and the others would lend their hands and intervene to any problem to resolve it. he further claimed that he feels more comfortable with girls and so he has more female friends than boys. he was admitted because of the presence of hallucinations. He and his neighbor misunderstood each other. the most traumatic experience he had is the death of his sister. During his school age.History of Present Illness The patient could remember that his mother told him that when he was sick with chickenpox and measles. . He claimed that he was brought to the hospital because of his hypertension. he usually don t mingle with the other patients but feels comfortable when talking to student nurses. but not identified. patient claimed he was generally healthy as a child. Aside from this. illusions and delusions. he keeps on digging at their backyard and always saying that may ginto sa likod ng bahay natin . He does not participate in school activities and seldom mingle with his classmates but as he grows up. due to financial matters he wasn t able to attend his sister s burial. At the age of 15. every now and then they are almost having an argument. he had high fever and convulsion.According to the patient.
He . due to financial matters he wasn t able to attend his sister s burial. he was only diagnosed with hypertension before admission at the Psychiatric Hospital. They got married and blessed with a son. After graduating. It was his first time to be separated from his family and so he felt so sad. However. According to the patient. The time he was firstly observed with manifestations of the disorder the patient was into treasure hunting. Being away from your wife and being with your son for a that he was really close to his sister. For his other siblings. They decided that his wife will go abroad also leaving their vacation. That is the time he feels very sad because he claimed 3 son with him. he visits them occasionally and whenever there was a problem with one of the member of the family he and the others would lend their hands and intervene to any problem to resolve it. the most traumatic experience he had is the death of his sister. he decided to work abroad in Saudi to earn his own money. It was during this time that he learned that his sister died from an accident. In order to sustain their needs of the family. He then met his wife who is a registered nurse in one of the Hospitals in Saudi. With this set up of a long distance relationship which is too hard to handle. In the case of our patient there was no mental illness in the family. he learned to be independent and so he was able to finish his chosen field of mechanical engineering. he is usually very happy. he continued to work abroad leaving his family in Zamboanga. he then have to be separated to his family because he enrolled to one of the schools in Baguio to finish his college degree. During his college years.after he graduated from high school.
high. excited. Since then. during the night when his son was watching t. Five days prior to admission.claimed that he met an old woman that was dictating him what to do and where to hunt. This was accompanied by an elevated mood and he had reduced sleep. After he went to Balatoc Mines. the patient stopped his treasure hunting activities and also claimed that he stopped seeing the old woman. One day prior to admission. the patient felt abnormally good. His friends were not visiting him anymore and vice versa. He had optimistic ideas and plans were expressed. but the patient wouldn t forget his position in the family and would do household chores and would act accordingly. the patient kept on saying S. He was helpful with doing house chores but noticed that he had lost his social life. He was observed to be happy during those times.B. and would walk around the house to and fro and he would utter incoherent words. the patient would dig around their backyard and was preoccupied with doing unnecessary things. This was extreme since the patient lost contact with reality and started to believe strange things. who was the patient s relative who worked in a mining company. He claimed that the old woman manipulated him to do it. He had poor judgment and behaved in harmful ways which was dangerous. The patient developed symptoms of hallucination and delusion. the patient came close to him saying. the patient s wife came home from Saudi. The patient started to mumble. Sino . hyperactive and irritable. The wife then went back to Saudi and after sometime the patient resumed his usual activities of digging around their house. and around that time he was observed to be normal again. Soon after.v.
has a noticeably proper cut hair and is well combed. (their neighbor whom he always had an argument with). He actively and openly answers queries being asked to him by the student nurses.BEHAVIOR 1. 3.R. he wears the usual t-shirt along with his shorts or any available pants he has. B. the son introduced himself. Out of fear.ka sino ka?.F. The patient was seen half naked. I. Afterwards. the patient went to his room shouting over and over again. P.Mental Status Examination A.R. For 3 consecutive days of duty. refers wearing long sleeves but when it is hot. it was observed that he only took a bath on the third day then changed his clothes. Mr. Mr. kissing the ground and saying that he is the savior. Hence patient I. manic with psychotic symptoms. His nails are trimmed and his beard and mustache are neatly shaved.APPEARANCE The client appears to be well groomed. current episode.MANNER OF RELATING Mr. wears clothing appropriately depending on his mood and with the weather. I.. I.. the son called their relatives and asked help from the nearby police station to get the patient. is participative during discussion. praying on the road. Mr. 56 years old was admitted and diagnosed with bipolar affective disorder. So. He was held and brought to the institution hence the admission.R.R. The patient had a bag of stones and books saying he would go home to Zamboanga leaving the treasure to 4 his son. the patient is observed to brush his teeth before and after meals. The client appeared as the stated age of 56 years old with visibly white hair and some noticeably wrinkles on his face. I.R. He ..
sleeping. He used simple. He has mild hand tremors observed.PSYCHOMOTOR ACTIVITES The patient has a good posture. Tagalog and Ilokano fluently.RELEVANCE/COHERENCE The client was able to answer relevantly and coherently. concrete and easy to understand responses to the topics being discussed during the NPI (Nurse-Patient-Interaction). swaying his feet while looking around the room. 4. 2. rhythm and intensity. He usually prefers to talk with student nurses rather than to his co-patients inside the ward. However. he shares some topics to be discussed. He usually stay on bed sitting or if not. clanging of words. Patient has 5good posture. 5.SPEECH/LANGUAGE The client talks with normal rate.sometimes cracks jokes that make the conversation lively. He elaborates his answers to questions asked and sometimes. Patient is able to talk in English. he sometimes slouches during conversation with his legs and arms crossed and sometimes with his hands on his lap. He was observed to walk straight. To explain further what are his thoughts. stammering. He speaks clearly and has good articulation of words. It was also observed that he can easily find the right words to use when lost during conversation. 3. rhyming. gait and station. repetition of words and speeches in particular .DEVIATIONS There were no deviation like inventing.
D. He talks about his family often and mentioned Yung asawa ko nagwork sa Saudi at may isa akong anak. I.R. May isa na akong apo. stated okay naman pero minsan nadedepress . .R. I. 6.THINKING During the conversation. He can identify who brought him to the ward. He was able to discuss recent events of the world and how these are predicted by previous events. time and self. C. place. when the topic is about the incident where he wasn t able to visit his sister and dad s burial.MOOD and AFFECT Mr. However the patient was observe he hospital.. He would use simple words to his co-patient while he uses more complex vocabularies to the health care providers. He sometimes use terms related to his field of engineering such as the different machineries and gadgets he encountered while he is still studying and working abroad. It was observed during the conversation that whenever the discussion deals with his wife finding time visiting him.R. is oriented to person. was able to discuss topics concerning religion. Mr. However. He also talks about his work and how was he as an employee when he works abroad. he becomes very sad with teary eyes. Mr.VOCABULARY The patient uses appropriate terms to use when conversing. There was no paranoid delusions observed from the client. Maaga nakapag asawa. philosophy and history. he feels very happy and is seen smiling.questions being asked by the student nurses noted. I. Patient is able to adjust his choice of words depending on whom he is talking to.
Malaking tao kasi. He can still recall up to now that he s 56 years old the memorable experience he had when he was 6 years old which made his parents got mad. Because he has the three signs of mania which are Auditory Hallucinations. to avoid topics which concern on the reasons why he was brought to E. he said Si Earl.PSYCHOPATHOLOGY 1. Siya yung una kong nakita nung pagpasok niyo.1 Increase Dopamine . He has the symptoms of depression like social withdrawal. . palagi kaming nabubuking kaya napapalo kami .Neurotransmitter Alteration A.2 Increase Serotonin level . He said May ilog kasi doon malapit sa bahay namin.A decrease in serotonin levels indicates depression. delusions and paranoia A. Naliligo kami ng walang paalam kaya pag-uwi namin.Overproduction of dopamine causes the nerve circuits to misfire and create a split state in the mind where delusions and hallucinations make the reality of the outside world easier to accept A.An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder.Biological Cause A.3 Decrease Serotonin Level . oo yung mataba. When the patient was asked to tell the name of one of our costudent nurse that was introduced to him for no longer than 15 minutes. low self- .The patient is able to recall recent and past events in his personal history.
Presented by poor IPR to other people.As presented by Long term depression C.3 Living alone for several years . Traumatic Experience C. Genetic Predisposition B.As manifested by anxiety and fear D.Because they have a close-knit family C. Use of Defense Mechanism .esteem and persistent sadness B.Being alone and independent in an area that is unfamiliar C.He has the presence of the type A personality.1 Separation from family members .It is according to Freud s Psycho-social theory. which is inherently acquired thus he has poor IPR to others 2.2 Death of his Sister . lack of close friends.Ineffective use of Denial as manifested by unrealistic perception of the situation . Cultural Norms . Development of Mistrust . unable to express feelings. social withdrawal B. isolates self. Psychosocial Causes A.1 Being Shy .
During admission until the third day patient has a fluctuating BP of 130/100 to 150/100. the Blood pressure will be maintained at 130/90 from 150/100 Dx: >Monitored vital signs especially BP >Assessed contributory factors of increase BP Tx: >Assisted in getting up slowly from bed to bedside or from supine to moderate high back rest >Assisted in going to the comfort room or using the commode if necessary >Promoted adequate rest by decreasing stimuli. providing quiet environment and scheduling activities Edx: >Instructed to report shortness of breath.S> Problema ko tong BP ko. this was caused by over excitement when his wife came home from Saudi and stress that causes sympathetic nervous system (that stimulates the fifgt or flight response) over activity increasing hearts contractility over stress. patient s Bp was maintained at 130/90 . tumataas Bp150/100 O> Fluctuating BP of 140/100 to 150/100 >Feeling of dizziness like when going to the comfort room >Increase respiratory rate >Fast breathing A> Altered cardiovascular status related to increase pressure secondary to HypertensionPati ent has a history Patient has a history of hypertension. patient was able to demonstrate understanding and techniques to prevent increase of BP LTO: Goal met. low sodium >Reiterated religious taking of medication >Encouraged rest periods as necessary >Note response to activities >To know the appropriate intervention >Patient might be getting up of bed in the wrong way which may add up in the increase BP >To provide safety >To maximize sleep periods that provide good energy source >Immediate interventions will be done >To maintain normal BP >To help regulate BP >To prevent sudden increase of BP STO: Goal met. Source: Brunner and Suddarth s MedicalSurgical Nursing 7 th edition STO: After 1 hour of health teaching.Proper Deep breathing exercises LTO: After 3 days of nursing intervention. patient will be able to demonstrate understanding of techniques and ways to prevent further increase of blood pressure like: a.Waking up slowly on bed and resting before walking b. chest pain or any discomfort >Emphasized importance of diet low fat.
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