Psych Final Case.

Calayan Educational Foundation, Inc.
Office of the College of Nursing

PACUCOA Level III Accredited
Related Learning Experience: Care Management of Clients

with Maladaptive Patterns of Behavior
LMMG General Hospital, Lucena City

Kalinga Center
In Partial Fulfillment of the

Requirements in the Related Learning Experience
NCM 117
Submitted by:
Group 4B
Averia, Ma. Kaye

Dalguntas, Aira Christine
Liwanag, Precious Grace
Mendoza, Katherine
Uy, Prince Leanard Adolfo
EDNA M. NEAMEYER RN, MAN

Clinical Instructor
1
CLINICAL EXPOSURE
KALINGA CENTER DEPARTMENT
FEBRUARY 18-19, 2023
FEBRUARY 25-26, 2023
TABLE OF CONTENTS
PAGE
Foreword 3
Acknowledgement 3
Objectives 3
Introduction 3
Case Scenario 4
Patient’s Data 4
Laboratory / Diagnostic Result 5
Anatomy and Physiology 6
Pathophysiology 8
Genogram 10
Physical and Mental Status 11
Medical Management 12
Nursing Care Plan
NCP 1 13
NCP 2 14
NCP 3 16
Drug Study 18
Medication Cards 19
Discharge Plan 19
Prognosis 20
2
CASE PRESENTATION
BRIEF PSYCHOTIC DISORDER SECONDARY TO
SUBSTANCE ABUSE
FOREWORD
This case study focuses on a psychiatric patient with Brief Psychotic Disorder secondary to
Substance Abuse. The authors of this study chose the type of illness to be discussed, from one of their
actual patients. The case study's presented discussion will attempt to demonstrate knowledge distribution
to their co-nursing students; and future researchers who would desire to dig deeper into this case study.
ACKNOWLEDGEMENT
This study is wholeheartedly dedicated to the faculty of College of Nursing and to our clinical
instructor Mrs Edna Neameyer for providing us knowledge and for giving us great insight to our future
profession, to our loving parents, who have been our source of inspiration and gave us strength, to our
classmates and friends and to our Alma Mater, Calayan Educational Foundation Inc.
To MMG Kalinga center for allowing us to use it as the place of learning to witness and
experience how to care around person with mental disability, to the medical director Nenita C. Tan
to the department head Dra. Carmelita L. Custodio, to the Chief Nurse Ma’am Judith de San Andres
and to the staff nurses that guided us throughout our duty, we thank their commitment and
supervision into molding us into the best future medical professional.
To our Patient B, Patient R for their cooperation and understanding in all our given activities
and therapies.
We'd also like to dedicate this case study to our fellow nursing students and other healthcare
members, to be used as a reference for future nursing interventions. Lastly, we thank God Almighty for
providing us with sufficient wisdom to accomplish this study.
OBJECTIVES
GENERAL OBJECTIVES:
The purpose of this case study is to provide deeper knowledge and understanding regarding the
subject of the study who is diagnosed with Brief Psychotic Disorder secondary to Substance Abuse.
SPECIFIC OBJECTIVES:
• Review the predisposing factors of Brief psychosis.
• Summarize the treatment options for Brief Psychosis.
• Explain the importance of improving care coordination among healthcare providers to improve
outcomes for patients affected by this specific psychiatric disorder.
• To give us an idea on how we could give proper nursing care for our client with this condition.
• To address the client’s health needs.
INTRODUCTION
Mental health encompasses emotional, psychological, and social well-being, influencing cognition,
perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and
decision-making.
A mental disorder is characterized by a clinically significant disturbance in an individual's cognition, emotional
regulation, or behavior. It is usually associated with distress or impairment in important areas of functioning.
This an acute mental health condition where there is a loss of contact with reality.
3
This is characterized by one or more of following features:
• A reduced level of social functioning
• Blunted or inappropriate affect
• Changes in perception due to hallucination
• Changes in thinking due to delusion
Symptoms of Brief Psychosis include a brief period of delusion, hallucination, disorganized thoughts and/or speech
with reduced motivation and/or initiative-taking compared to baseline state.
This might occur in the context of an acute stressor, such as bereavement, marriage breakdown, unemployment,
imprisonment, accident, childbirth, migration, or social isolation.
4
CASE SCENARIO
The patient is a 22-year-old male. The patient was living with his mother, father and one
sibling. His father reported having a history of schizophrenia. Patient has a positive behavioral
changes as reported by his mother. Prior to admission patient start from not sleeping well and only 2-
3 hours, talking to self, became verbally abusive and until became uncontrollable. Patient was
admitted at the ER reported that according to patient, ‘’Ako ang God of War’’ and according to
mother ‘’Nananakit na, sinuntok ang tatay at tiyo kanina’’
PATIENT’S PROFILE
Name: Patient B Birthday: August 17, 2000

Age: 22 years old Address: Lucban Quezon
Gender: Male Nationality: Filipino
Civil Status: Single Religion: Roman Catholic
Admission Date: 18 February 2023

Chief Complaint: Change on Behavior
Diagnosis: Brief psychotic disorder
Attending Physician: Dr. Salazar
QUESTIONS NO YES REMARKS

Do you have any allergy? (Mayroon ka bang allergy?) 
Do you have any chronic disease? (Mayroon ka bang pangmatagalang

sakit?)
Do you have any surgery? (Naoperahan ka na ba?) Please specify: 
Have you received blood transfusion before? Please specify: 
Have you received radiation/chemotherapy? (Ikaw ba ay

naradiation/nachemotherapy na?)
Pain (May masakit yper iyo? Gaano kasakit? 1- di masyadong masakit, 10-

sobrang sakit)
Excessive weight gain during the last 3 months (Pagtaas ng timbang sa

nakalipas na 3 buwan)
Special diet? (May special diet ka ba?) Please specify: 
Excessive Weight loss during the last 3 months (Sobrang pagbawas ng

timbang sa nakalipas na 3 buwan)
ECONOMIC
Living with family (Kapisan mo ba ang pamilya mo sa tahanan?) 
Number of children (Bilang ng anak) NA
Employed (May trabaho ka ba?) 
HABIT/SOCIAL
Alcohol use (Umiinom ka ba ng alak?) 
Tobacco use (Naninigarilyo ka ba?) 
Regular medications (May mga gamut ka bang iniinom sa araw-araw?)

Please specify: unrecalled prescribed medications
FOR MEN ONLY
Testicles Shrinking / Swelling / Discharge (Lumalaki ba o lumiliit ang

iyong bayag? Namamaga ypert? May tulo ka ba?)
5
History of Present Illness

8 Days PTA Not sleeping Well at night, 2-3 hours only per night.
10 Feb 2023 Swimming and drinks alcohol with friends.
6 Days PTA Talking to self with irrelevancies.
Talking about devils and dwarfs, restless, dancing and having panic attack
4 Days PTA Condition worsen and patient become verbally abusive, potentially aggressive and
going to the forest.
Removing his clothes and talking about God of Wars
1 Day PTA Become uncontrollable on and is aggressive, combative.
Kicking and pushing his father and uncle without any provocative.
Mother reported to MMG-ER then admitted
Medical Illness Mental Illness

(+) ypertension – Mother side (+) Schizophrenia (Sapi) – Father side
(+) Diabetes Mellitus – Grandmother
(+) Asthma – Patient
(+) Allergy – Amoxicillin
LABORATORY / DIAGNOSTIC RESULTS

Complete Blood Count
Interpretation:
Slightly elevated WBC is an indication that there is an infection causing the rise of the body’s
fighting cells. White blood cells which are part of our immune system have been found to play a
role in different brain diseases.
Interpretation:
Since the WBC of the pt. was slightly elevated it is common that the monocytes eosinophils and segmenter
will also be above normal. It indicates that the patient may have an infection.
6
 An increased percentage of neutrophils, called neutrophilia, may result from an inflammatory

disorder, from infection.
 A high monocyte count is a potential sign of many different medical conditions. It's often linked
to infectious diseases.
 A high eosinophil count can indicate that the body is producing lots of new eosinophils to try to
fight a bacteria, virus, or parasite. It is also indicates that the body is responding to an infection
or allergen.
Test Result Result Unit Reference Range Interpretation
Creatinine 71.60 44.2-106.1 Normal

Potassium 4.45 3.5-5.3 Normal
SGPT 35.9 41 Normal
Sodium 138.1 135-148 Normal
URINALYSIS
Interpretation:
2+ Urobilinogen represents the transition from normal to abnormal, the patients should be further
evaluated for hemolytic and hepatitis disease.
X-ray
FINDINGS:
7
Both lungs are clear

The heart is not enlarged.
Diaphragm and costophrenic sulci are intact
The rest of the chest structures are unremarkable
INTERPRETATION:
Essentially Normal Chest
ANATOMY AND PHYSIOLOGY
The brain is a complex organ that controls thought, memory, emotion,

touch, motor skills, vision, breathing, temperature, hunger and every
process that regulates our body. Together, the brain and spinal cord that
extends from it make up the central nervous system, or CNS.
Weighing about 3 pounds in the average adult, the brain is about
60% fat. The remaining 40% is a combination of water, protein,
carbohydrates and salts. The brain itself is a not a muscle. It contains
blood vessels and nerves, including neurons and glial cells.
The cerebrum (front of brain) comprises gray matter (the cerebral cortex)
and white matter at its center. The largest part of the brain, the cerebrum
initiates and coordinates movement and regulates temperature. Other areas
of the cerebrum enable speech, judgment, thinking and reasoning, problem-
solving, emotions and learning. Other functions relate to vision, hearing,
touch and other senses.
The brainstem (middle of brain) connects the cerebrum with the spinal
cord. The brainstem includes the midbrain, the pons and the medulla.
The cerebellum (“little brain”) is a fist-sized portion of the brain located
at the back of the head, below the temporal and occipital lobes, and above
the brainstem. Like the cerebral cortex, it has two hemispheres. The outer portion contains neurons, and the inner
area communicates with the cerebral cortex. Its function is to coordinate voluntary muscle movements and to
maintain posture, balance,e and equilibrium. New studies are exploring the cerebellum’s roles in thought, emoti,ons
and social behavior, as well as its possible involvement in addiction, au, aut,ism and schizophrenia.
8
• Frontal lobe. The largest lobe of the brain, located in the front of the head, the frontal lobe is involved in
personality characteristics, decision-making, and movement. Recognition of smell usually involves parts of
the frontal lobe. The frontal lobe contains Broca’s area, which is associated with speech ability.
• Parietal lobe. The middle part of the brain, the parietal lobe helps a person identify objects and understand
spatial relationships (where one’s body is compared with objects around the person). The parietal lobe is
also involved in interpreting pain and touch in the body. The parietal lobe houses Wernicke’s area, which
helps the brain understand spoken language.
• Occipital lobe. The occipital lobe is the back part of the brain that is involved with vision.
• Temporal lobe. The sides of the brain, and temporal lobes are involved in short-term memory, speech,
musical rhythm and, some degree of smell recognition.
9
PATHOPHYSIOLOGY
10
GENOGRAM
A genogram is a diagram illustrating a person's family members, how they are related, and
their medical history. The genogram allows the patient to see hereditary patterns of behavior and
medical and psychological factors that run through families.
The following diagram will illustrate the patient’s family and medical history.
The box without color represents a male and the circle without color represents a female.
The box-colored yellow will represent Schizophrenia and the box colored yellow-green will
represent psychotic disorder.
Interpretation:
The genogram shows that the father of the patient has a history of Schizophrenia so this will
be a predisposing factor for the patient history, it may aggravate the symptom the patient
experiencing from substance abuse that causes him a Brief psychotic disorder.
11
PHYSICAL AND MENTAL STATUS EXAMINATION
General Description Slightly obese
Mood and Affectivity Labile mood, agitated, potentially aggressive
Speech Characteristics Loud, verbally abusive
Perception:
a. Hallucinations  (Auditory Hallucinations)
b. Illusions 
Thought Content and Mental Trends

a. Flight of Ideas 
b. Looseness of associations 
c. Circumstantiality 
d. Tangentiality 
e. Pre-occupations 
f. Suicidal 
Sensorium Cognition
a. Consciousness: alert, fugue, cloudy, Cloudy
somnolence, stupor, coma
b. Oriented to time 
c. Oriented to person 
d. Oriented to place 
e. Remote memory Impaired
f. Recent memory Impaired
g. Immediate retention and recall Impaired
Concentration and Attention

a. Reading and writing Impaired
b. Visual-spatial ability impaired
c. Abstract thought Impaired
Judgement and Insight

a. Judgement poor
b. Insight poor
Reliability
a. Reliability poor
12
Insight
Intellect
Coping Mechanism
Defense Mechanism
MEDICAL MANAGEMENT
The patient is a 22-year-old male. The patient was living with his mother, father and one
sibling. His father reported having a history of schizophrenia. Patient has a positive behavioral
changes as reported by his mother. Prior to admission patient start from not sleeping well and only 2-
3 hours, talking to self, became verbally abusive and until became uncontrollable. Patient was
admitted at the ER reported that according to patient, ‘’Ako ang God of War’’ and according to
mother ‘’Nananakit na, sinuntok ang tatay at tiyo kanina’’
Findings:
Slightly Obese
Potentially aggressive
Verbally abusive
The physician decided to give our patient a Mental state examination on the first day,
Patient appearance and general behavior
Level of consciousness
Attentiveness
Motor and speech activity
Mood affect
Thought and perception
Attitude and insight
Higher cognitive abilities
Diagnosis: Acute psychotic disorder secondary to substance abuse
Physical examination
Positive for lesions and bruises in the right arm. Positive for dry lips
Feb 18, 2023

Day 1
Give Haloperidol 5mg plus diphenhydramine 50mg IM q8
Feb 20, 2023

Day3
Add Olanzapine 10mg 1 tablet at bed time
Feb 22, 2023

Day 5
Increased Olanzapine to 10mg 1 tab BID
13
March 2, 2023
Day 13
Start Lithium Carbonate 450mg ½ tab OD
March 4, 2023
Day 15
Patient was assessed by Dr. Salazar
Ordered patient MGH
Medications:
Haloperidol 5mg IM q8
Diphenhydramine 50 mg IM q8
Olanzapine 10mg, 1 tab BID
Lithium Carbonate 450mg ½ tab/day
14
NURSING CARE PLAN #01

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective After 3 • Assess for • Evaluate the After 3 sessions of

‘’hindi manlang coping sessions of individual stressors. feelings the nursing
nila ako secondary to nursing patient may interventions, the
pinuntahan dito’’ neurologic interventions, be having in patient verbalized
as verbalized by factors as the patient regard to fear appropriate coping
the patient evidenced by will verbalize about a strategies and
Objective: inadequate appropriate medication or resources to
• Lack of social support coping procedure, prevent ineffective
support system strategies and changes coping
system resources to relationship • Verbalize
• Verbalizes prevent with the
an ineffective parents.
inability to coping • Assess the patient’s • Facing
cope and support system and difficult
handle available resources. situation
stressors alone can
make them
 Use therapeutic appear
communication. daunting
• • Using
techniques
such as active
listening,
reflecting,
open-ended
questions, and
even silence,
student nurses
can foster
trusting
relationships
with patients
and further
explore
barriers to
their ability to
cope.
• Using
• Use therapeutic techniques
communication. such as active
listening,
reflecting,
open-ended
questions, and
even silence,
student nurses
can foster
trusting
relationships
with patients
and further
15
explore
barriers to
their ability to
cope
• tudent nurse
scan offer
available
options such
• Provide stress- as books,
relieving and music,
relaxation community
techques. ( Story singing,
tellin, misic and music, and
arts therapy and arts.
community
singing • he students
nurse can
offer an
• Encourage outside
participation. perspective to
assist the
patient in
recognizing
barriers and
changing
behaviors.
16
NURSING CAE PLAN #02

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIO
N
SUBJECTIVE Disturbed After nursing • Reorient the • Inability to After nursing
DATA: thought interventions patient to maintain interventions
“Dati nasa process/delusio were time/place/person orientation is a were
impyerno ako si n secondary to implemented , as needed. sign of implemented,
satan ang kilala Biochemical , the patient deterioration. the patient did
ko, pero nung neurological will maintain not maintain
napunta ako dito Imbalances as reality • Schedule • This provides reality
nakilala ko si God evidenced by orientation structured stimulation orientation and
at binigyan nya impaired and activities and rest while reducing still can’t
ako ng vision judgment, communicat periods. fatigue. communicate
hindi ko alam perception, and e clearly clearly with
kung gift ba ito or decision- with others. • Patient may others. The
sumpa,” as making. Patient will • Maintain a respond with patient still
verbalized by the also express pleasant and anxious or expresses
patient. delusional quiet aggressive delusional
material less environment and behaviors if material
OBJECTIVE frequently. approach the startled or frequently such
DATA: patient slowly overstimulated. as hearing
• gritting and calmly. things, although
teeth it’s positive.
• continuou
s hair • Delusional
stroking • Present reality patients are
• muscle concisely and extremely
tension briefly and do not sensitive about
• catatonic challenge others and can
• signs of illogical thinking. recognize
cynicism Avoid vague or insincerity.
evasive remarks. Evasive
comments or
hesitation
reinforces
mistrust or
delusions.
• This is to avoid
• Reduce triggering
provocative fight/flight
stimuli, negative responses.
criticism,
arguments, and
confrontations.
• Recognizing the
• Recognize and patient’s
support the accomplishment
patient’s s can lessen
accomplishments anxiety and the
(e.g. his ability to need for
17
control his delusions as a

emotions, source of self-
specifically his esteem.
anger, &
recognizing the
positive effects of
his confinement).
• Verbalization of
• Encourage the feelings in a
patient to non-threatening
verbalize true environment
feelings. Avoid may help the
becoming patient come to
defensive when terms with long-
angry feelings are unresolved
directed at him or issues.
her.
18
NURSING CARE PLAN #03
ASSESSMENT DIAGNOSI PLANNING NURSING RATIONALE EVALUATION

S INTERVENTIONS
SUBJECTIVE Risk for After nursing After nursing
DATA: Violence: interventions 1. Schedule ‐ This provides interventions
“Gusto ko ng Directed to were structured stimulation were
makalabas dito, others implemented, activities and while reducing implemented, the
gaganti ako sa secondary to the patient rest periods. fatigue. patient continues
kanila, dadalhin ko substance will refrain
din sila dito,” as abuse as from verbal
to express verbal
‐ Provides threats and loud,
stated by the evidenced by threats and 2. Use a calm structure and
patient. rage reaction. loud, profane and firm
profane language
control for a
language approach. toward others.
client who is
OBJECTIVE toward out of control.
DATA: others.
 gritting 3. Remain ‐ The client can
teeth neutral as use
 continuou possible; Do inconsistencie
s hair not argue with s and value
stroking the client. judgments as
 muscle justification
tension for arguing
 catatonic and escalating
 signs of mania.
cynicism
4. Reduce
provocative ‐ This is to
stimuli, avoid
negative triggering
criticism, fight/flight
arguments, responses.
and
confrontations.
‐ Helps decrease
the escalation
5. Decrease of anxiety and
environmental manic
stimuli (e.g., symptoms.
by providing a
calming
environment
or assigning a
private room)
‐ Clear and
consistent
limits and
expectations
minimize the
potential for
6. Maintain a clients’
consistent manipulation
approach,
19
employ of staff.
consistent
expectations,
and provide a
structured
environment.
20
21
22
DRUG STUDY #01
DRUG STUDY #02
18
DRUG STUDY #03
DRUG STUDY #04
MEDICATION CARD
19
DISCHARGE PLAN
GOALS STRATEGY OF IMPLEMENTATION EVALUATION
To Improve the  M- Instructed the patient and their immediate relatives  The patient/significant
patient's health by the value of taking all the prescribed medication others were able to
giving lectures on correctly. To reduce or eliminate symptoms and end the recall and understand
medications, the psychotic disorders, the doctor may recommend the importance of
environment, antipsychotic drugs. medications, the stress
treatments, health  E- maintained a therapeutic environment free from free and suitable
education, stressors like negative emotions and feelings and gave environment for the
outpatient referral, instructions to relatives on how to rid the space of any patient’s condition,
diet, and social and potentially harmful components that could induce treatments, outpatient
spiritual matters. psychosis. referral therapy, proper
 T- Antipsychotic medications are used to stop or slow diet and social and
the emergence of symptoms from a previous psychotic spiritual.
disorder. Psychotherapy and other forms of counseling
can be used to lower the risk of developing psychotic
disorders.
 H- Recognize the warning signs and seek assistance as
soon as you can, Modifications in the patient's thoughts,
feelings, and worldview.
 O- For advice, consult healthcare provider.
Psychotherapy, Mileu Therapy is a form of counseling.
The aim is to support the individual in identifying and
managing the circumstance or event that actually set off
the disorder.
 D- A balanced diet. A lower risk of depression is linked
to a diet that is plentiful in fruits, vegetables, nuts, and
legumes; moderate amounts of poultry, eggs, and dairy
products; and only occasionally red meat. Omega-3
fatty acids may benefit mental health.
 S- Stress free life is encourage as well as being
optimistic to have a better outcome and faster recovery.
20
PROGNOSIS
Patient a 22-year-old male was admitted at MMG Lucena City kalinga with the chief complaint of
changes in behavior, with the diagnosis of a brief psychotic disorder. Characteristics of his disorder are
hallucination, Aggressive or unpredictable behavior, and delusions. The patient is no longer aggressive,
have improved his behavior and no signs of hallucination and delusions with the time span of no longer
than one month.
Good Prognosis
The patient was:
 Able to go home in good condition
 Had a good behavioral outcome
 Able to participate in therapies
21

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Calayan Educational Foundation, Inc.

Office of the College of Nursing

Related Learning Experience: Care Management of Clients

LMMG General Hospital, Lucena City

In Partial Fulfillment of the

Averia, Ma. Kaye

EDNA M. NEAMEYER RN, MAN

Name: Patient B Birthday: August 17, 2000

Admission Date: 18 February 2023

QUESTIONS NO YES REMARKS

History of Present Illness

Medical Illness Mental Illness

LABORATORY / DIAGNOSTIC RESULTS

 An increased percentage of neutrophils, called neutrophilia, may result from an inflammatory

Test Result Result Unit Reference Range Interpretation

Creatinine 71.60 44.2-106.1 Normal

Both lungs are clear

ANATOMY AND PHYSIOLOGY

The brain is a complex organ that controls thought, memory, emotion,

PHYSICAL AND MENTAL STATUS EXAMINATION

General Description Slightly obese

Mood and Affectivity Labile mood, agitated, potentially aggressive

Speech Characteristics Loud, verbally abusive

Thought Content and Mental Trends

Concentration and Attention

Judgement and Insight

Diagnosis: Acute psychotic disorder secondary to substance abuse

Feb 18, 2023

Feb 20, 2023

Feb 22, 2023

NURSING CARE PLAN #01

Subjective: Ineffective After 3 • Assess for • Evaluate the After 3 sessions of

NURSING CAE PLAN #02

control his delusions as a

NURSING CARE PLAN #03

ASSESSMENT DIAGNOSI PLANNING NURSING RATIONALE EVALUATION

DRUG STUDY #01

DRUG STUDY #02

DRUG STUDY #03

DRUG STUDY #04

GOALS STRATEGY OF IMPLEMENTATION EVALUATION

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