ILIGAN MEDICAL CENTER COLLEGE

SAN MIGUEL VILLAGE, PALA-O, ILIGAN CITY

TEL. NO. 221-4661 - FAX NO. 221-6584

CASE PRESENTATION
ACUTE PSYCHIATRIC WARD

BIPOLAR 1 DISORDER MRE MANIC WITH PSYCHOTIC FEATURES

Submitted by: Group 1

Anadon, Jezel

Casan, Rahima

Juni, Marianne Angel

Maba, Norjihan

Malawani, Norlailah

Marcera, Jeraldine Alessa

Rashid, Norhanisah

Sarabusing, Jennie Rose

INTRODUCTION

Definition:

Bipolar Disorder is a mental illness characterized by severe mood swings from episodes of mania to episodes of
depression. Bipolar 1 Disorder has at least one episode of mania, which is a period of abnormally elevated,
expansive, or irritable mood, along with increased energy or activity. Bipolar 2 Disorder is characterized by
patterns of depressive episodes and hypomanic episodes.

GENERAL OBJECTIVES:

After 16 hours (4 days) of nursing care interventions, the student nurses achieved a thorough comprehension of
patients with the same diagnosis, encompassing its manifestations and clinical outcomes, identified potential risk
factors, evaluated treatment strategies and enhanced the overall patient care. Additionally, they developed skills
in critical thinking and communication, and cultivated attitudes such as empathy, professionalism, and
commitment to continuous learning and improvement.

SPECIFIC OBJECTIVES:

● Provide a definition of bipolar disorder, its symptoms and diagnostic criteria

● Determine the impact of psychotic symptoms on overall functioning, including relationships and daily
activities
● Identify potential triggers or stressors that may contribute to the onset or exacerbation of the symptoms.
● Understand the anatomy and physiology of the affected system
● Investigate the developmental milestone, diagnostic and laboratory test results with its significance

Brief Statement of Client’s Case

Patient X, is a 24 year old, was admitted on June 28, 2024, with a diagnosis of Bipolar 1 Disorder most recent
episode manic with psychotic feature.

For the reason “Dili na siya maminaw, dili na mo lingkod, sigeg tuyok-tuyok”, as verbalized by the S.O. The
Patient also verbalized “My mother thinks I’m crazy. I’m not crazy, all of us got panic attack.”

Rationale for Choosing the Case:

This case was chosen to be able to appreciate the complexity of the disorder and the comprehensive learning
opportunities it provides. This case offers valuable insight into the multifaceted nature of health management,
including the importance of medication adherence and the role of family involvement in treatment compliance.
By examining this case, we can explore the necessity of a holistic treatment plan that includes medication
management, psychotherapy, lifestyle modifications, and potentially spiritual support. This case study will
enhance our understanding of managing psychiatric conditions and highlights the importance of coordinated,
multidisciplinary approach to improve patient outcomes.

Biographical Data

Patient’s Name: Patient X

Age: 24 years old
Gender: Female
Date of Birth: April 8, 2000
Religion: Roman Catholic
Educational Attainment: Grade 11
Chief Complaint:
● Behavioral changes
● “Dili na siya maminaw, dili na mo lingkod, sigeg tuyok-tuyok” as verbalized by the S.O
● “My mother thinks I’m crazy. I’m not crazy, all of us got panic attack” as verbalized by the patient
Admitting Diagnosis: Bipolar 1 Disorder most recent episode manic with psychotic feature
Final Diagnosis:
Date of Admission: June 28, 2024
How many days from admission: 9 days
Attending Physician: Dr. Winston Lantajo, MD
REASON FOR ADMISSION
Hours before admission, the patient’s mother noticed behavioral changes in her daughter and was
displaying signs of confusion. She was roaming around the neighborhood saying “Galagot ko sakong mama kay
iyang payton akong anak”, she then hid in a parked motorcycle verbalizing that someone would kill her.

CLIENT’S PERSONAL HISTORY

The patient was born to a G1P1 mother, delivered post- term. She was an only child to a single mother.
At an early age, she was a stubborn child who always retaliated when her mother reprimanded her. She was raped
at the age of 15 years old. At the age of 17 years old, she got pregnant by her Filipino boyfriend and left the baby
to her mother’s care. Her relationship with his Filipino boyfriend didn’t work out. She got into multiple
relationships with Chinese men. Eventually she got married to a Chinese man but got separated due to abuse. She
went home from China and had a relationship with another Chinese man studying in Cebu.

HISTORY OF PRESENT ILLNESS

9 months PTC, patient moved to China to join her husband and live with him. No initial abuse happened

6 months PTC, the patient expressed that she wants to return to the Philippines which her husband opposed.
Following this both husband and mother-in-law began verbally and physically abusing her. She started self-
harming to gain sympathy and to allow her to leave

5 months PTC, she escaped back to the Philippines. During this time her mother noticed that the patient was
irritable, distractable, and exhibits grandiose delusions about wealth. Patient also displays pressured speech and
rapidly shifting topics

2 days PTC, the patient went to a mall to buy a new phone. However, the mall was about to close and the sales
lady refused to sell her a phone. Patient reacted violently and was restrained and detained in jail

10 hours PTC, patient was released and went home. In their home, her mother noted that her daughter behaved
indifferently. According to her mother, the patient was looking of her daughter even though her daughter was just
beside her sleeping. The patient then carried her daughter and roamed around the neighborhood saying “galagot
ko sa akong mama kay patyon niya akong anak”. Patient then hid in a parked motorcycle and said someone will
kill her. Hence, family decided to seek consult.

FAMILY GENOGRAM
PSYCHOSOCIAL ASSESSMENT

General The client is fairly-groomed, clothes are appropriate for her age, weather and situation.
Assessment and Client’s posture is erect and sometimes restless, agitated, and keeps on pacing around
Motor Behavior the room. Client maintains eye contact. Her voice is soft and clear. The content of the
client’s speech is relevant to the question being asked.

Mood and Affect Mood: Client reported feeling hopeless. When asked why, she said “Feeling nako
nabuhat na nako tanan” and the client started to cry.
Affect: During assessment, the client's affect was restricted. She displayed one type of
expression which is somber and maintained a monotone voice throughout the session.

Thought Process Thought Process: Client was able to answer questions appropriately and her responses
and Content were relevant to the topic. Client stayed focused on the questions and provided direct
answers.
Thought Content: Client thought content was heavily focused on feelings of
hopelessness. Client denied experiencing any delusions or hallucinations.

Sensorium and
Intellectual Client was alert and responsive throughout the assessment. She maintained attention
Processes and was able to engage in conversation without difficulty. Client was fully oriented
to the person, place and time. “Ako si Patient X and today is July 3, 2024 and it is 7
in the morning. Naa ko karon sa Vicente Sotto” as verbalized by the client.

Abnormal Sensory Client denied experiencing any hallucinations and illusions. She does not report any
Experiences or misinterpretations of actual external stimuli.
Misconception

Judgment and When client was asked why she did not want to be restrained, she stated that “Dili man
Insight sa maulaw ko irestrained kay kabalo man ko na equal ta tanan dinhi sa mental hospital.
Ang ako lang is dili ko komportable kung irestrain ko. Ma trigger akong anxiety.”

Self-concept
Client appears to have a low self-esteem as she verbalizes that she feels hopeless.
Although she expressed this, she stated that “Gusto na jud ko mo uli” and is eager to
comply with her medications for her to return home. She also stated that she wants to
be a psychiatrist someday.

Roles and
Relationship Client is the only child of her mother, who stated that despite living under the same
roof, they do not have a close relationship7. They have poor communication. The
client has a 4-year-old daughter, whom she left in her mother's care at the age of one
month. According to the client's mother, although the client is not emotionally close
to her daughter, she still provides for her material needs.

Physiological and Sleep Pattern: Client reported having a good sleep. On average, she gets about 6-8
Self-Care hours of sleep per night.
Considerations Appetite: The mother reported that the client eats less amount of food. Sometimes the
client will not eat at all, especially if she did not like the food being served.
Personal Hygiene and Grooming: The patient is fairly-groomed. The mother states
that the client takes a bath every day.
PHYSICAL ASSESSMENT (HEAD TO TOE ASSESSMENT)

Body Part Normal Findings Patient Findings Significance

Skin and Nails Without lesions and SKIN: No presence of lesions,

Suggests that the patient is
rashes, warm to touch skin is warm, dry, no rashes and
and dry, without edema, well-hydrated and in good
fair complexion.
has good skin turgor, no overall health, without any
NAILS: Fingernails and toenails
tenting. signs of infections or systemic
are both trimmed, smooth, firm,
problems. It also indicates good
clean with translucent color and
circulation.
no presence of clubbing, capillary
refill within 2 seconds.

Head, Eyes, HEAD: Normocephalic; HEAD: Head is symmetric, round The head appears symmetrical
Ears, Nose, symmetrical, smooth in shape no presence of lumps, with no apparent abnormalities.
Neck, Throat skull contour masses, and lesions, has golden
EYES: PERRLA, extra
brown hair color and well
ocular movement intact
distributed and no lice or dandruff
(EOMI), no nystagmus
and optical disks sharp noted.

EARS: flesh color; Pupil is equal in size, round,

positioned centrally and EYES: Pupils are equal and round reacts to light, and no
in proportion to the head; with good accommodation, no abnormalities are observed in
No foreign bodies, signs of nystagmus, with non the eye.
redness, drainage,
sunken eyeballs and eyes are
deformities, nodules, or
brown in color No abnormalities and
lesions
NOSE AND MOUTH: discharges seen in the ears.
External nose is EARS: Symmetrical, shows no
symmetrical with no signs of lesions, tenderness,
discolouration, swelling redness, swelling, or discharge. No abnormalities and
or malformations. Nasal discharges seen in nose and
mucosa is pinkish red
NOSE and MOUTH: mouth
with no
Symmetrical, no nasal discharges
discharge/bleeding,
swelling, malformations are noted, sense of smell are intact
or foreign bodies and appropriate from common
NECK: the trachea scents, complete teeth with slight
should be midline; has no yellow in color, with braces both
enlargement of lymph upper and lower, moist lips and
nodes or thyroid gland.
tongue no presence of lesions.

NECK and THROAT: No Typically suggests the absence

thyroid enlargement noted. No of certain conditions like goiter
lymphadenopathy, gag reflex is or lymphadenopathy
present.
Musculoskele- Erect posture with good UPPER EXTREMITIES: Able Movement and sensation are
tal balance and normal gait to move independently intact in both extremities.
while walking. Joints and LOWER EXTREMITIES: No
muscles are symmetrical
signs of muscle atrophy, patient
with no swelling,
demonstrates good balance and a
redness, or deformity.
Active range of motion normal gait while walking.

of all joints without

difficulty. No spine
curvature from posterior
view

Respiratory Chest wall is symmetric Equal chest expansion, clear There is no indication of any
without deformity and is breath sound and a respiratory rate abnormalities in the chest.
atraumatic in appearance. within normal, initially 20 cycles
No tenderness is noted
per minute with oxygen saturation
upon palpation of the
of 99%
chest wall. No signs of
respiratory distress.

Cardiovascu- PMI is not visible and is Regular heart rate, distinct heart There is no evidence of any
lar palpated in the 5th sound noted without any heart disease.
intercostal space at the murmurs.
midclavicular line. Heart
Initial blood pressure of 120/80
rate and rhythm are
mmHg, pulse rate of 90 bpm
normal

Gastrointes- Abdomen is soft, Abdomen is soft, flat, nontender, There is no evidence of any
tinal symmetric, and and normal active bowel sounds abdominal abnormalities.
nontender. There are no are noted.
visible lesions or scars.

Genitourinary Absence of pain or The patient voids 3-5 times daily, Indicates that hydration levels
System tenderness, absence of with urine that is light yellow in are sufficient and kidney
masses voluntary color and odorless. Initially 800 function appears to be normal.
guarding; clear, pale
ml of urine. Defecates
yellow urine, absence of
approximately 1x a day yellow to
pain urgency, frequency
or retention; brown in color, formed and
nondistended bladder smooth in texture with mild odor.

Reproductive No lesions, swelling, The patient is currently using There is no evidence of any
inflammation and contraceptives depo injection. other abnormalities.
tenderness.

Nervous Alert and oriented to Alert and oriented to person,

person and place and Cranial nerves are all intact
System place, and time. No motor deficits
time. No motor deficits are noted, with muscle strength
are noted, with muscle
5/5.
strength 5/5 bilaterally.
Sensation is intact
bilaterally
 Cranial Nerve:

I. Olfactory- Patient is able to

describe odor.
II. Optic- Patient has 20/20 near
and far vision.
III. Oculomotor- Pupils are
equal, round, and reactive to light
and accommodation.
IV. Trochlear- Intact extraocular
movements (eyes move together
and, in all directions, smoothly).
V. Trigeminal- Patient feels
touch sensation on the forehead,
maxillary, and mandibular areas
of face and chews without any
problems.
VI. Abducens- Both eyes move in
coordination.
VII. Facial- Patient smiles, raises
eyebrows, and closes eyes without
difficulty; patient can distinguish
different tastes.
VIII. Vestibulocochlear
(Acoustic)- Patient hears
whispered words, can walk
upright and maintain balance.
IX. Glossopharyngeal- Gag
reflex is present.
X. Vagus- Patient swallows and
speaks without difficulty.
XI. Spinal Accessory- Patient
shrugs shoulders and turns head
side to side against resistance.
XII. Hypoglossal- Tongue is
midline and can be moved without
difficulty.

Suicide Patient has no thoughts Patient displays feeling of The patients shows some
of harming himself and hopelessness which is another suicidal thoughts and
others even when he/she symptom of a suicidal and feature.
is in a hostile/angry state. depressed person.
Also, patients are not
making threatening
remarks about family or
another person.
 BEFORE DURING
GORDON'S
HOSPITALIZATION HOSPITALIZATION
FUNCTIONAL
HEALTH
PATTERNS

NUTRITIONAL Prior to hospitalization during the patient’s Upon hospitalization the patient has no appetite. She
METABOLIC younger years, he had a good appetite and doesn't eat food served in the ration. “dili niya gusto
PATTERN was able to consume 3 meals a day which ang pagkaon nga gina served, dili sha mukaon” as
include rice, fried egg, soup, fish, fruits and verbalized by the so. Her fluid intake is still the same
especially vegetables. She usually drinks as his prior admission. The Doctor allows her to eat a
alcoholic drinks at events. Her fluid intake diet as tolerated and the client has allergies to peanuts.
prior to hospitalization is usually 1L per day. Patient is independent in feeding.

ELIMINATION Prior to admission the patient usually voids According to the patient, she urinates the same way
PATTERN 3-4 times a day, yellowish in color and as before, yellowish in color and odorless, without
odorless, without dysuria. She defecates dysuria. He defecates approximately once a day,
approximately once a day, yellowish or yellowish or brownish in color, with the normal smell
brownish in color, with the normal smell of of feces.
feces.

ACTIVITY The patient shows moderate physical activity

During admission, the patient liked to roam around
AND since she was able to go out walking and go
and pace in the room but engaged in minimal
EXERCISE to the mall to go window shopping. She also
physical activity, but sometimes she's asleep the
PATTERN can perform her daily living activities such
whole morning after taking a bath and drinking
as feeding, bathing, dressing and toileting
medicine. However, she maintained her ability to
independently.
perform activities of daily living such as feeding,
bathing, dressing, and toileting without change.

SLEEP-REST The patient was admitted on June 28, 2024, with a

The patient sleeps usually 6-8 hours with no
PATTERN diagnosis of Bipolar 1 Disorder, most recent episode
interruption unless the patient feels the urge
manic with psychotic features. According to her
to void. She usually spends her day outside
mother she usually sleeps around 8pm and wakes up
and is unable to rest well enough.
at 5am, with sudden awakenings during midnight.
However, this indicates an improvement to his rest
pattern.

COGNITIVE- The patient displays normal sensory The patient displays normal sensory perception,
PERCEPTUAL perception, including taste, smell, touch, including taste, smell, touch, hearing, and visual
PATTERN hearing, and visual acuity. The patient acuity. However, the patient exhibits good learning,
exhibits good learning, thought processes, thought processes, and good memory, and intellectual
and good memory, and intellectual functioning. The patient was able to answer questions
functioning. and her responses are relevant to the topic. Patient
was heavily focused on feelings of hopelessness.
Patient denied experiencing any delusions or
hallucinations.

SELF-
The patient prefers to go out shopping The Patient displays low self-esteem and prefers not
PERCEPTION
 AND SELF- According to the significant other (SO), the to communicate with others. The client focused on
CONCEPT patient is observed to engage in suicidal feeling hopelessness. “Gusto nako mo uli” as
PATTERN behavior. “Galaslas siya saiya kamot” as verbalized by the patient. “I feel so hopeless feel nako
verbalized by the SO. nabuhat na nako tanan” as verbalized by the patient.

ROLE- According to the significant other (SO), the Upon admission, the patient is not that sociable or
RELATIONSHI patient is active at home helping with house friendly. Additionally, she is not dependent on her
P PATTERN chores and loves to cook. But most of the mother; she takes a bath when told to do so. However,
time the patient prefers to be alone and sleep she does not require assistance with dressing and
in her bedroom. other aspects of personal care.

SEXUAL During late childhood, the patient did not During the patient's hospitalization, she does not
REPRODUCTI show intimacy or attraction to the opposite depend on his mother to change his clothing.
VE PATTERN sex. However during the early adolescence, Additionally, she shows no more interest in intimate
the patient shows intimacy and attraction to relationships with the opposite sex.
the opposite sex. During also in the ealy
adolescense the patient got raped by the
neighbor. There was a weak connection and
relationship with her mother and father, as
she did not spend much time bonding with
them.

COPING- According to the patient, she loves to cook During hospitalization, the patient becomes restless
STRESS and go to the mall when she’s stressed. She and sometimes just sleeps the whole shift. The patient
TOLERANCE loves doing window shopping on her own. s is not violent. But she always shows and says she's
PATTERN She tends to avoid solving problems and hopeless by saying “I feel hopeless, feel nako nabuhat
continues to evade them. When faced with na nako tanan” as verbalized by the patient.
problems, she reacts by isolating herself, Additionally, she doesn't make conversation with the
walking everywhere, and window shopping. other patient in the ward because she says she's not
sociable and does not make friends.

VALUES The patient does not attend church because Her family believes in God, and do attend church
BELIEF she said she believes in Allah. She wants to every Sunday, but the patient doesn't want to join her
PATTERN become muslim and pray to Allah. family. She says she believes in Allah. “Kay Allah
lang ako naniniwala na nagkakaroon ng pagbabago at
nakakapag heal” as verbalized by the patient. The
patient also cried when we asked about why she wants
to be a muslim and who influenced her to believe in
Allah. “My first boyfriend (crying) siyay naka pa
influence nako nga mutuo kay Allah kay sa Allah siya
musimba. She also says she misses the guy.
“Gimingaw nako niya, dugay nakayko wa kakita
niya” as verbalized by the patient.
 ANATOMY AND PHYSIOLOGY

The Central Nervous System comprises the brain, the spinal cord, and associated nerves that control voluntary acts.
Structurally, the brain consists of the cerebrum, cerebellum, brain stem, and limbic system.

CEREBRUM

- is the largest part of the brain and is responsible for many higher brain functions.

Divided into two hemispheres:

● Left hemisphere controls the right side of the body and is the center for the logical reasoning and analytic
functions like reading, writing, and other mathematical tasks.
● Right hemisphere which controls the left side of the body, and the center for creative thinking, intuition, and
artistic abilities.

The cerebral hemispheres are divided into four lobes:

1. Frontal, involved in executive functions such as decision making, problem solving, planning, and voluntary motor
control. Also responsible in large part for a person’s affect, judgment, personality, and inhibitions.
2. Parietal, processes sensory information related to touch, temperature, pain, and spatial awareness
3. Temporal, involved in auditory processing, memory formation, and language comprehension.
4. Occipital, primarily responsible for visual processing.

CEREBELLUM

- located below the cerebrum, and is the center for coordination of movements and postural adjustments. It receives
and integrates information from all areas of the body.

BASAL GANGLIA

- located in the deep cerebral hemisphere that are responsible for control of fine motor movements.

BRAINSTEM

Is crucial part of the brain that connects the brain to the spinal cord and controls many vital functions necessary for survival,
this includes:

● Medulla,
- located at the top of the spinal cord, controls autonomic functions such as heart rate, blood pressure, and
respiration.
● Pons
- acts as a bridge between different parts of the brain, particularly the cerebellum and the cerebral cortex. It
plays a key role in motor control, sensory analysis, and functions in arousal and consciousness.
● Midbrain
- involved in vision, hearing, motor control, sleep/wake cycles, arousal (alertness), and temperature
regulation.

LIMBIC SYSTEM

The limbic system is an area of the brain located above the brainstem that includes:
 ● Thalamus regulates activity, sensation, and emotion.
● Hypothalamus is involved in temperature regulation, appetite control, endocrine function, sexual drive, and
impulsive behavior associated with feelings of anger, rage, or excitement
● Hippocampus and Amygdala are involved in emotional arousal and memory

NEUROTRANSMITTERS

Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information
throughout the body

● Dopamine, a neurotransmitter located primarily in the brain stem, plays several important roles in the body; it involves
movement, pleasure, motivation and drive, mood regulations, cognitive and attention.

● Serotonin, a neurotransmitter that plays a vital role in various physiological and psychological processes. Key functions
of serotonin include: sleep, appetite and digestion, memory and learning and social behavior.

PATHOPHYSIOLOGY
FREUD’S PSYCHOANALYTIC THEORY

STAGES FINDINGS SIGNIFICANCE

● According to the mother, her child was mostly breastfed for 3 years and a half. ● During the oral stage of psychosexual development, which lasts from birth to about
Oral She was breastfed every 2 hours and even when her child was not crying. During 18 months, an infant's primary source of interaction is through the mouth. In the case
(0-18 months) infancy, her child did not experience being bottle fed. She added that her daughter described, the child was breastfed every two hours for 3.5 years and did not
experience bottle feeding or pacifier use. The child started eating solid food at 9
started eating solid food at 9 months and eats food by picking it up using hand as
months and fed herself by hand. Thumbsucking was limited to teething periods.
a way of feeding herself. Her daughter only thumbsucked when she was teething.
Mother also mentioned that her daughter did not experience using pacifiers. ● The extended breastfeeding likely fulfilled the child's oral needs, fostering a sense of
security and attachment. While this may prevent oral fixations during the oral stage,
prolonged breastfeeding could potentially lead to oral fixation behaviors later in life.
Overall, the child's oral stage development appears well-nurtured, but long-term
effects would depend on factors such as the weaning process and emotional
development.

● The mother stated that her daughter wore a diaper until 2 years old. At 3 years old, ● During this stage, a child's focus of pleasure and conflict centers on the anus and
Anal she would get her mother’s attention by mumming “oo-oo” to signify that she activities related to defecation. The mother's report suggests that the child is
(18-36 months) wants to defecate. The child was cooperative and that she did not have any progressing normally through the anal stage of psychosexual development. The
problems in potty training her. child’s cooperative behavior and lack of problems in potty training indicate a healthy
relationship with bodily control, which Freud believed would contribute positively
to the development of personality traits such as orderliness, conscientiousness, and
self-control.

● The patient was with the mother, aunts, and cousins during this stage. She did not ● Overall, while the child had a supportive female environment, the absence of a father
Phallic have any relationship with her father. figure and the need to live with an aunt due to her mother's work could indicate that
(3-5 Yrs.) ● It was during this time that she’s left at the home of her aunt because her mom the phallic stage was not fully resolved according to Freud's criteria. This incomplete
works as a maid. resolution might affect her future relationships and sense of gender identity.

● At school-age, the patient was able to make a lot of friends in school. She was also ● While the patient exhibited significant signs of successfully engaging with the
Latency into paintings and drawing. latency stage, such as making friends and developing hobbies, the behavioral issues
(5-11/13 Yrs.) ● It didn’t last long as the patient started to go home late because of the barkadas. and the necessity of parental monitoring suggest that the stage was not fully met
She learned that the child had learned to cut class, when the mother found out, she according to Freud's criteria. The presence of both positive and challenging elements
said that she tried to stop it and from then on, always monitored her. indicates a mixed outcome for the latency stage.
 STAGES FINDINGS SIGNIFICANCE
● At around 13-14 years old, the patient’s father, who has a record of being a drug ● In the case of a non-consensual sexual penetration, the patient's experience does not
Genital addict, showed up in her life for the first time, and brought her with him to the align with the successful resolution of Freud's genital stage. This stage is not just
(13 years old ktvs and bar. Patient stated that this is the time she learned to drink alcohol and to about physical sexual maturity but also about forming consensual, healthy, and
onwards) smoke. When the mother found out about this, she got very angry and tried to stop responsible sexual relationships.
their relationship.
● At the age of 15, the patient experienced of being raped by a neighbor during a ● The trauma associated with non-consensual sex can significantly disrupt the
fiesta in the Leyte Ormoc. emotional and social development necessary for navigating this stage. Addressing
● At the age of 17, she got pregnant by a pinoy boyfriend. But the relationship didn’t the trauma through appropriate psychological and social support is crucial for helping
last long as the guy just vanished. She stopped school because of this. the patient move toward a healthier integration of their sexual identity and
relationships.

ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY

STAGES FINDINGS SIGNIFICANCE

● The patient's mother stated that she attended to her daughter's needs alone,
Trust vs. Mistrust sometimes, with the help of the mother’s sisters. During infancy, she holds ● This stage is crucial for developing a sense of trust when caregivers provide reliable
(0-1 Yr.) her daughter, especially only when crying. After which, she puts her on a care and affection. In this case, the patient might have developed a basic sense of
‘duyan’ to sleep. trust if the care provided was consistent, even if it was limited to times of distress.

● According to her mother, the patient was able to feed herself through hand
Autonomy vs. Shame and picking. The child communicates whenever she has the urge to defecate and ● Successful navigation of this stage results in a sense of autonomy and confidence.
Doubt urinate. The patient's actions suggest she was developing autonomy, indicating a positive
(2-3 Yrs.) ● The mother also stated that the child showed signs of stubbornness in wanting resolution of this stage.
to choose her own clothes at this time.

● Despite limited resources, the patient exhibited creativeness when playing.

Initiative vs. Guilt For instance, creates airplanes using bond paper, she draws princesses figures ● This stage is about asserting control and power over the environment. The patient’s
(4-6 Yrs.) and sells them out to friends for 1 peso, and uses lata as telephone play with creativity and initiative in play and chores suggest she likely developed a sense of
friends. initiative and purpose, successfully navigating this stage.
● The child was also trained to help with household chores such as washing her
 own dish, sweeping floors and folding her clothes.

● The mother mentioned that her daughter was very interested in Art class and
Industry vs. Inferiority actively participated in poster-making activities during elementary school. ● This stage focuses on coping with new social and academic demands. The patient’s
(7-12 Yrs.) She was very strict about her attendance and would cry if she had to miss a engagement in school activities shows a sense of industry. However, feelings of
day. jealousy and inferiority due to financial constraints could indicate a mix of positive
● During this time, the mother noticed that her daughter felt jealous and and negative outcomes in this stage.
demanded things she saw her classmates having, like rectangular bags and
nice clothes, which the mother couldn’t always afford due to financial
constraints.

● Around 13 years old, the patient started coming home late, drunk. The mother ● The patient's experiences indicate a high risk of role confusion rather than a
Identity vs. Role eventually discovered that her daughter had been cutting class. Upon finding successful resolution of this stage. The significance lies in the need for supportive
Confusion out, she tried to stop this behavior and began closely monitoring her daughter. interventions to help the patient develop a stronger, more coherent sense of identity.
(13-19 Yrs.) ● At the age of 15, the patient experienced of being raped by a neighbor during ● Drinking alcoholic beverages early hinders the development of a stable and
a fiesta in the Leyte Ormoc. coherent identity, potentially leading to role confusion.
● At the age of 17, she got pregnant by a pinoy boyfriend. But the relationship ● Rape, such trauma can contribute to confusion about personal identity and roles, as
didn’t last long as the guy just vanished. She stopped school because of this. it disrupts the normal process of exploring and establishing one's identity.
● Becoming pregnant by a boyfriend who then abandons her can lead to feelings of
abandonment, inadequacy, and further confusion about personal relationships and
identity.

● From then on, she started to have multiple partners, specifically chinese. ● Multiple Partners and Financial Dependence Indicates challenges in forming deep,
Intimacy vs. Isolation ● She stated that she's the breadwinner of the family and that she has been a committed, and emotionally intimate relationships, potentially leading to isolation
(21-39 Yrs.) hustler since she’s 16 years old. When asked of the specific work, she said despite having partners.
“Wala, naa lang ga provide/sponsor skoa” ● Marriage and In-law Issues- Shows an attempt at achieving intimacy through
● Got married at the age of 23 years old with a Chinese man and lived with him marriage, but external relational issues disrupted this, reflecting difficulties in
for months in China. It didn't work out as she experienced abuse from the in- maintaining a stable intimate relationship.
laws.
● Went back to the dating stage and had multiple boyfriends, specifically
Chinese men again.
PIAGET’S COGNITIVE THEORY

STAGES FINDINGS SIGNIFICANCE

Sensorimotor According to her mother, the patient has had no early developmental experiences or The child's stable early environment fosters supportive interactions crucial for sensorimotor
(Birth-2 Yrs.) potential disruptions such as early hospitalizations, accidents, or abuse. At this age, the development. Babbling marks the start of language acquisition, vital for communication
patient started babbling sounds to communicate and learned to reach for and grasp objects progression. Developing fine motor skills through grasping objects emphasis on sensory
she wants. She also began to identify the senses of taste, touch, hearing, vision, and smell, learning and physical interaction. Increasing sensory awareness forms the basis for cognitive
and started to develop grasping skills. and emotional growth.

Preoperational At this age, the patient's ability to use language for communication begins to develop. She Early developmental stages essential for holistic growth and learning. Symbolic
(2-7 Yrs.) is able to express herself using understandable words and language, understand the meaning representation enables imaginative play and comprehension of abstract concepts. Socializing
of symbolic gestures, and classify objects and colors. She began making friends at the age with peers cultivates early social skills and interpersonal abilities. School enriches social
of 4, socializing with her cousins. By the age of 5, she started going to school and continued development through structured learning and peer interactions, fostering cognitive growth
to make friends. and expanding understanding of the world. These experiences collectively contribute to the
child's holistic development, emphasizing the interconnectedness of social interactions,
cognitive abilities, and emotional growth during early childhood.

Concrete The patient at this age, she can apply logical thinking especially in school where she was At this age, children demonstrate systematic problem-solving and grasp cause-effect
Operations also into paintings and drawing because it’s her way to express her feelings and her passion relationships. Engaging in school activities reflects their growing emotional expression and
(7-11 Yrs.) for the arts motivated her to engage in school activities. involvement in structured tasks, supporting cognitive development by integrating emotions
and cognition. Personal interests and motivation are crucial in fostering active learning and
deeper subject understanding during this stage.
 Formal Operations According to the mother, the patient is capable of defining, applying, and evaluating right This rigidity in accepting feedback or acknowledging errors despite understanding abstract
(11 Year Onwards) from wrong, as well as understanding its consequences. However, her insistence on always principles suggests a potential difficulty in integrating feedback into her decision-making
being right, even when making poor choices, makes it difficult for her mother to critique process. It may reflect challenges in applying her abstract thinking to real-world situations
her mistakes. and adjusting her beliefs or behaviors accordingly.

LABORATORY TEST

CHEMISTRY SECTION JUNE 29, 2024

RESULTS NORMAL VALUES SIGNIFICANCE

Sodium 142 135.00 – 145.00 mmol/L Within normal range

Potassium 4.17 3.5 – 5.00 mmol/L Within normal range

Chloride 106 98 – 107 mmol/L Within normal range

Ionized calcium 1.251 LOW 1.12 – 1.32 mmol/L Below normal range may indicate Vitamin D
Deficiency: Impaired calcium absorption in the
gut.

Creatinine 0.54 0.05 – 0.10 mmol/L Within normal range

Blood Uric Acid 3.92 HIGH 0.20 – 0.42 mmol/L Above normal range may be due to Dietary
Factors: High intake of purine-rich foods and
beverages that may lead to several health issues
like gout, kidney stones

Blood Urea Nitrogen 14.57 1.26 – 3.17 mmol/L Within normal range
 FBS 4.17 4.10 – 5.80 mmol/L Within normal range

JUNE 30, 2024

RESULTS NORMAL VALUES SIGNIFICANCE

Sodium 142.10 135.00 – 145.00 mmol/L Within normal range

Potassium 4.17 3.5 – 5.00 mmol/L Within normal range

Chloride 106.90 98 – 107 mmol/L Within normal range

Ionized calcium 1.25 1.12 – 1.32 mmol/L Within normal range

JUNE 30, 2024

HEMATOLOGY SECTION

RESULTS NORMAL VALUES SIGNIFICANCE

WBC COUNT 7.13 3.95 - 11.21 Within normal range

RBC COUNT 3.79 3.81 - 5.81 Within normal range

HEMOGLOBIN 124 121.4 - 179.8 Within normal range

HEMATOCRIT 40 36.85 - 54.32 Within normal range

MCV 106 HIGH 78.89 - 101.00 Above normal range may indicate or causes by
Vitamin B12 deficiency, Folate deficiency,
Alcoholism,

MCH 32.60 26.10 - 33.97 Within normal range

MCHC 309 LOW 320.0 - 362.0 Below normal range may indicate that the red
 blood cells have less hemoglobin than normal,
and may due to Iron deficiency anemia

DIFFERENTIAL COUNT

RESULTS NORMAL VALUES SIGNIFICANCE

Neutrophils 44.83 LOW 55 - 65 Below normal range may indicate viral

infections, Nutritional Deficiencies: Lack of
vitamin B12, folate, or copper.

Lymphocyte 40.900 HIGH 25 - 35 Elevated lymphocyte may indicate viral

infections, Stress: Physical or emotional stress
can temporarily increase lymphocyte levels

Monocytes 6.540 3 - 11 Within normal range

Eosinophils 7.260 HIGH 2-4 Above normal range may indicate due to
Allergic Disorders

Basophils 0.507 0-1 Within normal range

DRUG STUDY

NAME OF DRUG DOSAGE/FREQUENCY/ MECHANISM OF INDICATION CONTRAINDICATIONS SIDE EFFECTS NURSING

ROUTE OF ACTION PRECAUTION
ADMINISTRATION

Generic Name: Sodium 500mg/tab/2 tabs Enhances the action of treatment of several Contraindicated for Confusion, cough, crying, -Regularly assess the
Valproate Acid gamma-aminobutyric neurological and hypersensitivity, liver delusions, diarrhea, patient's mood, behavior,
acid (GABA), an psychiatric conditions disease or hepatic headache, feeling of and mental status.
inhibitory including: epilepsy, dysfunction, urea cycle unreality, trouble sleeping
Classification: Mood neurotransmitter, which bipolar disorder, disorders, mitochondrial and thinking. -Monitor weight and
stabilizers helps stabilize mood and migraine disorders assess for signs of weight
prevent manic episodes prophylaxis, agitation, gain and metabolic
and Reduces neuronal impulsivity, and changes.
excitability and stabilizes aggression.
mood by affecting ion -Regularly check for signs
channels. of liver dysfunction.

- Monitor for symptoms

of pancreatitis.

-Regularly monitor
plasma valproate levels.

-Be cautious of potential

interactions with other
medications
NAME OF DRUG DOSAGE/FREQUENCY/ MECHANISM OF INDICATION CONTRAINDICATIONS SIDE EFFECTS NURSING
ROUTE OF ACTION PRECAUTION
ADMINISTRATION

Generic Name: 10mg/tab OD It acts primarily by Used in the management Allergy to olanzapine, Sedation, Constipation, Assess history of allergy
Olanzapine antagonizing dopamine of schizophrenia, bipolar Myeloproliferative abdominal pain, to olanzapine.
D2 receptors and 1 disorder, and agitation disorders, Severe CNS headache,akathisia
Classification: serotonin 5-HT2A associated with these depression Encourage patient to void
Atypical Antipsychotics receptors, which helps disorders. before taking the drug to
balance the help decrease
neurotransmitter activity anticholinergic effects of
that can contribute to urinary retention
psychotic symptoms.
Inform patient about
the purpose and
importance of drug

Caution is advised in
elderly patients, especially
those with dementia-
related psychosis, due to
an increased risk of
mortality.
ASSESSMENT DIAGNOSIS PLAN/ INTERVENTION RATIONALE EVALUATION
OBJECTIVE

SUBJECTIVE Risk for self- Within 4 days of nursing INDEPENDENT: INDEPENDENT: After 4 days of nursing
CUES; directed violence care, the patient will: 1. Assess the patient’s level of risk for self-  To identify the severity of risk and care, the goal was
Patient’s r/t mental health directed violence. implement appropriate safety partially met as the
significant other
issue as  Demonstrate reduced measures. patient:
verbalized, “iyang
evidenced by frequency of self-  To prevent the patient from
gi parok iyang ulo
history of self- harming behaviors. 2. Create a safe environment by removing harming themselves when feeling  Demonstrated
sa dingding kayharming and any potential hazards. distressed. reduced
galagot siya”. observed  Express feelings and frequency of self-
behavior of emotions in a non- 3. Develop a therapeutic relationship with  To build trust and encourage the harming
OBJECTIVE banging head destructive manner. the patient, providing empathy and active patient to share their feelings and behaviors.
CUES; against the wall listening. thoughts.
 Pacing  Develop a safety  Expressed
 Scars on plan and identify at 4. Teach and encourage the use of  To provide the patient with healthy feelings and
wrists least two coping alternative coping strategies, such as outlets for managing stress and emotions in a
 Restricted strategies to manage relaxation techniques, journaling, or emotions. non-destructive
affect distress. physical activity. manner.

 Verbalize 5. Involve the patient’s family or  To provide additional support and  Haven’t
understanding of the significant others in the care plan as ensure the patient has a support developed yet a
triggers for self- appropriate, with the patient’s consent. system. safety plan and
harming behavior. identify at least
two coping
DEPENDENT: strategies to
DEPENDENT: manage distress.
1. Administer prescribed medications as
ordered and monitor for therapeutic and  To manage underlying mental  Verbalized
adverse effects. health conditions that may understanding of
contribute to self-harming the triggers for
behaviors. self-harming
behavior.
ASSESSMENT DIAGNOSIS PLAN/ INTERVENTION RATIONALE EVALUATION
OBJECTIVE

SUBJECTIVE Powerlessness r/t Within 4 days of care, the INDEPENDENT: INDEPENDENT: After 4 days of care, the
CUES; history of patient will be able to: goal was partially met as
“Gibuhat na nako domestic violence 1. Assess the patient’s level of risk for self-  To understand the extent of the the patient:
ang tanan, bahala as evidenced by  Identify areas over directed violence. patient’s feelings of powerlessness
na mo unsa verbalization of which individual has and tailor interventions accordingly.  Identified areas
inyong lack of control control. over which
hunahunaon”, as over life  To create a safe and supportive individual has
verbalized by the circumstances,  Express sense of 2. Establish a therapeutic relationship with the environment that encourages the control.
patient emotional control over the patient through consistent, empathetic, and patient to express their feelings.
distress, and present situation and nonjudgmental interactions.  Expressed sense
OBJECTIVE passive behavior. future outcome.  To provide the patient with a sense of control over the
CUES; of accomplishment and control over present situation
 Pacing  Verbalize feelings of 3. Encourage the patient to set realistic and their life. and future
 Scars on increased control achievable goals. outcome.
wrists over their life.  To provide the patient with a
 Restricted support network and tools to  Wasn’t able to
affect  Engage in activities 4. Encourage participation in support groups manage their emotions and regain a verbalize feelings
that enhance self- or individual therapy to address feelings of sense of control. of increased
efficacy. powerlessness and build coping strategies. control over their
 To help the patient challenge and life.
5. Teach and reinforce the use of positive self- change negative thoughts that
talk and cognitive restructuring techniques. contribute to feelings of  Haven’t engaged
powerlessness. yet in activities
that enhance self-
 To boost self-esteem and provide efficacy.
6. Promote involvement in activities that the opportunities for the patient to
patient enjoys and excels at. experience success and control.

DEPENDENT:
DEPENDENT:  To ensure the medication's
1. Administer prescribed medications as effectiveness and patient safety by
ordered and monitor for therapeutic and promptly addressing any potential
adverse effects. side effects.
 ASSESSMENT DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION

Subjective Hopelessness After 16 hours (4 Independent After 16 hours (4 days) of

“I feel so hopeless related to related days) of nursing  Establish therapeutic  Facilitates trust and allows nursing care, the patient was be
kay ako najud gi to chronic stress as care, the patient communication expression of feelings able to
buhat ang tanan” as evidenced by will be able to  Provide emotional  Reduces feelings of isolation
verbalized by the expression of support and enhances comfort Short term
patient despair and Short term  Teach relaxation  Involvement with supportive  Recognize and verbalize
verbalization of  Recognize techniques others provides emotional feelings (goals met)
hopelessness and  Facilitate social support validation and reduces  Identify and use of coping
Objective verbalize  Educate on coping skills isolation mechanism to counteract
 Restricted feelings  Teaching coping strategies feelings (goals not met)
Affect  Identify and empowers effective stress
 Low energy use of management and enhances Long term
levels coping resilience  Develop coping strategies
mechanism (goals not met)
to  Improve social support
counteract (goals not met)
feelings Dependent
 Administer  Helps manage depressive
Long term antidepressant symptoms associated with
 Develop medications hopelessness
coping  Provide counseling or  Offers professional support to
strategies therapy sessions address underlying
 Improve psychological factors
social contributing to hopelessness
support
DISCHARGE PLANNING

Medication:
 Patient will be prescribed with anticonvulsant and atypical antipsychotic medications such as Valproic Acid (2 tabs of 500mg/tab) and Olanzapine (1 tab of 10mg/tab once a
day) which she will be instructed to not discontinue without consulting her primary healthcare provider.

Exercise:
  Encourage patient to engage in regular physical activity, aiming for at least 30 minutes a day, 5 days a week.
 Choose activities that are enjoyable and can be done safely (e.g., walking, yoga, swimming).
 Consider gentle exercises that can help improve mood and energy levels without causing excessive fatigue.

Treatment:

The treatment plan for the patient includes:

 Individual therapy focused on managing bipolar symptoms, addressing trauma from abuse, and developing healthy coping mechanisms.
 Group therapy is recommended to connect with others who have bipolar disorder or have experienced trauma, providing mutual support.
 Family therapy will involve family members to enhance communication and support within the household.

Health Teaching:
 Educate the patient and family about Bipolar I Disorder, its symptoms, and management strategies.
 Teach about the importance of medication adherence and recognizing early signs of relapse.
 Remove any potential self-harm tools (e.g., sharp objects, medications not in use).
 Ensure a supportive and non-abusive environment.
 Provide hotline numbers for suicide prevention if available.

Outpatient Follow-Up:
 Encourage patient to adhere to psychiatrist appointments for regular monitoring of mood, symptom changes, and adjustments of medications.
 Compliance to appointments of counselor sessions help in developing coping mechanism and manage stress.

Diet:
 Follow a balanced diet, focusing on nutrient-rich foods such as, vegetables and fruits.
 Eat small, frequent meals to help manage low appetite.
 Include high-protein snacks and healthy fats to maintain energy levels.
 Consider consulting with a dietitian for personalized nutrition advice.

Spirituality:
 Engage in spiritual practices that bring comfort and peace (e.g., meditation, prayer, attending religious services).
 Connect with a spiritual advisor or community for additional support.
 Use spirituality as a source of strength and resilience during recovery.

PROGNOSIS
 For a patient with Bipolar I disorder who has experienced abuse and self-harming behaviors in the past, the prognosis is moderately positive. Strong support networks, secure,
non-abusive environments, and adherence to treatment and medical care are essential for a successful outcome. A healthy diet, regular exercise, and spiritual activity can all improve
general well-being. Managing trauma from previous abuse, avoiding self-harm, and dealing with any drug adverse effects are among the difficulties. Despite these difficulties, she can
attain stability and enhance her quality of life with regular care and assistance. Sustained success requires regular follow-ups.