Patient profile

Name of patient: J.A.L

Address: San Carlos, Pangasinan
Age: 21
Religion: roman catholic
Civil status: single
Occupation: none
Date admitted: June 1, 2018
Time admitted: 5: 45 pm
Birthdate:
Birthplace: san carlos, pangasinan
Admitting diagnosis: bipolar affective disorder, manic with mood congruent psychiatric
symptoms

Objective of patient nurse interaction:

THE OBJECTIVE OF NPI IS TO BUILD TRUST AND RAPPORT; ESTABLISHED THERAPEUTIC
ENVIRONMENT AND PRIVACY; ESTABLISHE MODE OF COMMUNICATION ACCEPTABLE TO BOTH PATIENT
AND STUDENT NURSE. INCLUDE ASSESSING MENTAL STATUS EXAMINATION AND GAINING INFORMATION
ABOUT THE PATIENT THAT WILL BE INTERPRETED ACCURATELY.

SETTING
In Psychiatric ward of BGHMC inside the female ward. We were with 6 patient and 5 student
nurses. Aside from that we have the client watcher, Mrs. L, mother of the patient. She appears
interested to converse with us. To start the nurse patient interaction the student nurse is sited
on the client bedside. The patient is just sited in front of the student nurse and minimum
distance is maintained with the student nurse and the client. The client maintained a moderate
eye to eye contact and face to face position of the client to the student nurse.
 Mental Status Examination

General appearance
This is 21-year-old single, female, lived in San Carlos City, Pangasinan and was casually dressed in a
blue t-shirt, red long sleeve, blue 3/4th short pant and a black slipper. The client is 4’11 in height and
weight of 55 kilograms. For the general appearance the client dress appropriately to age, weather and
setting but older than the chronological age; with good grooming and hygiene. Client accessibility in a
friendly manner; co-operative because when you say: “sit or sleep”, the client obey on the command and
respond appropriately for questions that is being asked; with good eye contact during the interview and
conversation; the client is trying to establish close rapport during the orientation phase. No smelly odor
noted. Client facial expression appears happy, smiling, responsive, and interested throughout in
orientation, working and termination phase.

Psychomotor Behavior
For the psychomotor behavior the patient is in a normal gait as evidenced by coordinated and rotatory
movements of body segments. When I tried to have a handshake to the client and a firm handshake was
her respond as a sign of assuredness and strength. Noted a relaxed posture when observing the client,
the feet are spread wide and the palm of her hands are facing outward. The rate of movements of the
client is slightly hyperactive as a signs of difficulty in remaining seated, walk about, and difficulty of
sleeping. Coordination of movements is agile a quick and coordinated of movements.

Mood and affect

For the mood the client appeared to be calm and comfortable; smiled when telling or seeing
something that makes her in a good mood. Affect is appropriate and congruent to situation; range of
affect is lively; attitude toward student nurse during encounter is open because she will say all of what
she thinks and her feelings; specific mood or feelings observed is optimistic because she reflect a
favorable view of events and conditions and expectation of positive outcome, other one is elation a
feeling of joy. Over all anxiety level is rated as mild.

speech
Speech volume is normal, rate of speech is rapid, flow of speech is expansive, intensity of volume is
ordinary, clarity of speech is relevant, liveliness of speech is lively and quantity of speech is offers more
information when asking a question.

cognition
Cognition include attention and concentration such as sufficient a truth of statement, and telling
some stories of months and years backwards. The memory is average for recent events of last few hours
and days; average for remote events of past years and still remembered of her nieces, nephews and some
member of her family birthdays. The client is oriented of place, day, time and her name. Judgement is
able to come to appropriate conclusions.

Thought patterns
 Thought of patterns for clarity is coherent and relevant to topic being discussed. The flow of thoughts
is pressure of speech when talking quickly and in such away that interruption is difficult. The thought
content is rhymes as she expresses her feelings and concerns.

Level of consciousness
On the level of consciousness the client is responsive to touch and verbal stimuli.
 Easter College

Easter School Road, Guisad, Baguio City

Department of nursing

PSYCHIATRIC WARD of
BGHMC
Rotation dated: June 11 and 13, 2018

Submitted by:
Salvara Jane C. Daniel

Submitted to:
Ma’am lilia Dungala

Submitted on:
june 13, 2018