PSYCHIATRIC PATIENT ASSESSMENT INDIVIDUAL CASE STUDY STUDENT: ERNESTO S. MALAMION III PATIENT: N.D. 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 disorder with psychotic symptoms. She was admitted because she could not sleep. She went to NCMH 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 in NCMH because she didnt follow the instructions of her doctor when she went out of NCMH on 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 the present was on September 05 of this year. All of her confinement was at the National Center 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 the interviewer) 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 her nurse and others. Her behavior seems to be like a normal person. She always crosses her legs 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. DATE: SEPTEMBER 29, 2012 AGE: 40 YEARS OLD

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 feels happy 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 was moderately difficult to established a discussion pertaining specific event in her life. b) Content (i.e. Delusions, ideas of reference, obsessions, preoccupations, suicidal ideations) None 7. Perceptual Disturbances The patient denied illusions and hallucinations in all modalities. She also claimed that could already 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 to answer 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 mental illness and is willing to follow all of the doctors order to become mentally healthy again. She has 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 of sleeping. This was her 3 confinement since her first on March of the same year. She was diagnose with Bipolar Disorder with Psychotic symptoms. The patient has no family history of mental illness. She has one son and a husband but separated. Her 3 confinement is at the National Center for Mental Health. It looks like she displays a normal behavior compared to the other patients although her mental ability seems to be slightly 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 lack of appetite. Self care deficit related to hygiene as evidence by body odor.

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.