Ateneo de Zamboanga University

College of Nursing
RLE WEEK #_______

Name: ______________________________________ Date: __________________

Scenario: EMERGENCY ROOM

March 11, 2022

7am-3pm shift

At 7:38 am, Susan Trinidad, 25 years old is taken by ambulance to the emergency room. The emergency room
nurse performing the assessment gathered the following information of Susan:
 Awake/conscious
 experiencing fear or abandonment
 Labile mood
 Impaired judgement
 Lacerated wound on forearms
 Vitals signs : T-37.3 C, respiratory rate of 22 breaths per minute, pulse rate of 105 beats per minute, O2
sat of 98, blood pressure of 90/60 mmHg

 weighs 60 kgs and is 162 cm tall

 No allergies/ no childhood illnesses

Susan was born on May 12, 1997, unemployed, Filipino, a Roman Catholic and resides at San Jose Road Cawa-
Cawa. She has been attending college sporadically but has only 15 completed credits and no real career goal.
She is angry because her parents have told her she must get a job to support herself. Last week, she met a
man in the park and fell in love with him on the first date. She has been calling him repeatedly, but he will not
return her calls. Yesterday, she decided to consult a psychiatrist, but refused medication and admission. About
30 minutes ago, she slashes her forearms with a sharp knife. She then calls 911, stating, “I’m about to die!
Please help me!.”

Admitting Diagnosis: Borderline Personality Disorder.

Medications ordered by ER doctor: Haloperidol 0.5 mg q 8 hours initially and Bacitracin ointment 550 unit/g q8
hours
Tasks/activities: (Based from the above scenario)
1. Fill out the patient’s admitting record.

Ateneo de ZamboangaUuniversity Medical Center

ADMITTING RECORD/ER RECORD

TO BE FILLED IN BY ER NURSE

Hospital No.00090
Last Name: Trinidad First Name: Susan Middle Name:M
Age:, 25 years old Sex: female Birth Date: May 12, 1997 Civil Status:single
Address: resides at San Jose Road Cawa-Cawa.
Arrival Date and Time: March 11, 2022, at 7:38 am, Birth Place: Zamboanga city Occupation: unemployed
Religion: Roman Catholic Nationality: Filipino

Time seen:___7:38am_____
Vital signs: TEMP: T-37.3 C R/R: 22 b/min
P/R: 105 b/min BP: 90/60 mmHg
Weight: 60 kg Height: 162 cm
Patient classification:
Emergent: __/__
Urgent: ____
Non-urgent:____

TO BE FILLED IN BY PHYSICIAN
Time seem:___7:39am____
Chief complaint: Labile mood, impaired judgement

History and Physical Examination: awake, labile mood, impaired judgement

(+) lacerated wound on left and right forearm
1 day prior to admission, patient sought consult with psychiatrist

No allergies, no childhood diseases

Impression/Diagnosis: Borderline Personality Disorder

Treatment/ Management: Admit to Psychiatric ward

 2. Using the format below make a sample admitting notes utilizing the FDAR charting, and carry out the
doctors order. FDAR stands for Focus (F), Data (D), Action (A), and Response (R ).

DATE/TIME FOCUS/PROBLEMS PROGRESS NOTES

(Data Action Response)
04/22/2022 Ineffective Coping D- “I’m about to die! Please help me!.” As verbalized by
patient.
 experiencing fear or abandonment
 Labile mood
 Impaired judgment

TEMP: T-37.3 C
R/R:22 b/min
P/R: 105 b/min
BP:90/60 mmHg
Weight: 60 kg
Height: 162 cm

A-
-Assess for self-mutilating or suicide thoughts or behaviors.

-Clients with BPD can be manipulative.

- Encourage the client to explore feelings and concerns (e.g.,

identify fears, loneliness, self-hate)

- Be nonjudgmental and respectful when listening to client’s

feelings, thoughts, or complaints.

- Interventions often call for responses to client’s intense and

labile mood swings, irritability, depression, and anxiety:

- Work with the client on problem-solving skills using a situation

that is bothering the client. Go step by step:

.Define the problem.

.Explore alternatives.

.Make decisions.

- Clients with BPD benefit from coping skills training (e.g., anger
management skills, emotional regulation skills, interpersonal
skills). Provide referrals and/or involve professional experts.

- Provide and encourage the client to use professionals in other

in other disciplines such as social services, vocational
rehabilitation, social work, or the law.

R-
Client was able to response to the intervention that was
implemented during nursing shift, client was able to
response “wait nurse, kumakalma na ako, teka, kaylanan ko
lng huminga ng malalim” as verbalized by patient.
TEMP: T-37.3 C
R/R:19 b/min
P/R: 95 b/min
BP:100/60 mmHg
Weight: 60 kg
Height: 162 cm