Saad Fahad Alabbad

2220005739

Inpatient W1

Dr. Aysar

6 November 2023
 Saad Fahad Alabbad 2220005739
26 October 2023 6 November 2023

Mr. MS 54 Male Saudi

Muslim N/A Arabic
Married 5
2
Good From his daughter
No

Writer in the emirate of Eastern Since 10 years

yes —
—
Reciting the Quran and walking for 30min in Dammam corniche

No No No No No N/A
5 years Depakine
No —

No
Schizoaffective disorder, Manic type

No
No
No
No
No
No
No
No
 Yes He faced pressure from his family by taking treatment
and going to the hospital for hospitalization

— — Yes
Yes, Father

— — — — —
Yes — — — —

Yes — —

Yes — — —

Schizoaffective disorder, Manic type

16 December 2022
17 times
Yes
Yes
Yes
Depakine

Yes

patient said that( ‫) حسيت بالضغط من اهلي وبناتي وعشان يرتاحون وارتاح جيت‬

Grandiose delusion, euthymic mood, and he gives the call to prayer and prays in a very loud voice
Several years, since up of 10 years
 Showed appropriate
Yes
Yes facial expression
Yes

Yes — Clothes aren’t weird

—

166 109 Obesity (PMI 42)

—
Relax and comfortable
Yes —
— No Absent of scars and tattoos

Yes
Yes — Hair: Black, clean and shine
—
—

Yes — Able to do ADLs

—
— Yes — appears as a fat man

Walk normally, without any abnormal

— — — Normal behavior such as catatonic behavior.

Yes Maintain eye contact, not distracted

— and attention well
 Yes
No
No Full consciousness man
No
No

Yes Yes Yes

— — — Oriented to surrounding

No Not aware about his condition

Yes He is conscious and reliable to

Yes
make decision

No
No He is aware and able to perceive
No — what is going on around him

He is reliable and oriented, because he

came to seek help with full satis ed

Yes Patient attentive

— —
 Yes
— He sleep well.
— —

excellent

No Remember event with greater

details from many years ago
No
Hypermnesia

— — — —
— Yes Go from topic to another
topic.
— — — Normal form of thinking
Yes Delusion of grandeur
— — He has a strong religious beliefs
— Yes — And he write letters to the king
thinking he is in a high position
— — Normal speech
— — Normal

No No has ability to control impulses

Yes He has a good knowledge and life

experience
 Yes
There isn’t any ideas of homicidal,
suicidal and self injurious behavior
Yes
Yes

Once 3 times There isn’t any abnormally of

No
bowel and urinary habits

Rice with chicken

N/A
N/A Eat suf ciently and has a good
Three meals per day appetite
Yes
Yes

— — —
— — —
— — —
— — — He has stable mood
— —
Stable mood
Yes
— He has stable affect
Yes —
— — — —
—
Stable affect
 Yes Receive, send and listen with full
Yes
Yes attention

Yes
Yes He is a social person
— And communicate with
others correctly
Yes
Yes
—

— — — There isn’t any abnormal

motor activity
— —
—
— Bizarre behavior when he
— Bizarre behavior is Pryer only
 Complete blood count

sodium valproate, haloperidol, benztropine and clozapine

 Saad Fahad Alabbad Mr.MS
54
Ward 1 Schizophrenia
2220005739 6 November 2023
Group 1

Clozapine Po 50mg BID for 5d

To reduce risk of suicidal behavior Drowsiness, dizziness and weight gain•
in patients with schizophrenia Contra with agranulocytosis disorder. •
Caution with a history of seizures or cardiovascular disease.
Regular monitoring of white blood cell counts.
Haloperidol To treat severe behavioral problems Drowsiness, dizziness and restlessness•
IM 50mg OD for 2w in adults, such as sever agitation. Contra with Parkinson's disease. •
Caution with a history of seizures, liver or kidney disease.
Monitored signs of tardive dyskinesia, as facial grimacing.
To treat severe behavioral problems Drowsiness, dizziness and restlessness•
Haloperidol Po 10mg OD for 7d in adults, such as sever agitation. Contra with Parkinson's disease. •
Caution with a history of seizures, liver or kidney disease.
Monitored signs of tardive dyskinesia, as facial grimacing.
To treat Parkinson's disease and drug Dizziness, dry mouth & blurred vision. • Caution with seizures, heart and kidney or liver disease.
Benztropine Po 2mg OD for 7d induced extrapyramidal symptoms. Contra with narrow-angle glaucoma. • Monitored signs of anticholinergic toxicity, as confusion.
To treat bipolar disorder, migraine Drowsiness, dizziness, and vomiting. • Caution with history of bleeding and improve pt safety.
Sodium valproate Po 500mg BID for 7d headaches, reducing seizures. Contra with liver disease. • Regular monitoring of liver function and platelet counts.
 Saad Fahad Alabbad 2220005739. Male Group 1

Ward 1 Schizoaffective disorder, Manic type

• Grandiose Altered thought The client will

delusion process related to demonstrate a reduction 1. Assess the client's level of cognitive The goal is met
impaired ability to in grandiose delusional impairment and delusional thinking. within one week
2. Provide the client with a safe and
• Euthymic mood process as evidence thoughts and improved
supportive environment.
as evidence by
by grandiose ability to process interact on reality
• he gives the call delusion information within one 3. Teach the client coping skills to based topics.
to prayer and week as evidence by manage their grandiose delusional
prays in a very interact on reality based thoughts.
loud voice topics. 4. Encourage the client to participate in
activities that promote cognitive
function and social interaction within
• Not aware about his physical capabilities and tolerance.
his condition

• Obesity (BMI 42)

• Remember
event with
greater
details from
many years
ago

• He has a
strong
religious
beliefs

• Bizarre
behavior
when he is
Pryer only
 PROCESS RECORDING

Student’ name: Saad Fahad alabbad Group: - 1 Date of Session: 6 November 2023
-
Patient description upon initial approach:-
The patient was well dressed, oriented, cooperative and hygienic
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Goal To knowing the reason of admission and express his feelings
…………………………………………………………………………………………

Person Verbal and Non verbal interaction

Student’s Professional
Analysis & feeling

Me Hello, how are you

Patient Hi, I’m doing well Patient seen want to talk

Me My name is Saad a student nurse. May I ask you questions?

Patient Yes, why no? Patient is cooperative and

answer questions.
Me Ok good, What’s your name

Patient My name is Mr. M

———-
Me Ok Mr. MS, Can you tell me what is the reason for you.
coming here ?
Patient Well, I faced pressure from my family to taking treatment
and coming for hospitalization. And by the time, I come Patient seen careworn.
here for them

Me Well, I understand you. Do you have any problems such

as sleeping or eating here ?
Patient No, everything is okay here even nurses are very
helpful. So alhamdulalah Patient seen delightful.

Me Ok, thanks you Mr. M for your cooperation. I nished my

questions So do you have any questions and things you
want to say?
Patient No, thanks I will watch tv now and when i want Patient seen interested in tv
something i will call you
 College of Nursing
Psychiatry and Mental Health Nursing (NURS-304)
Third Year- Fifth Level
Academic Year 1445 (2023-2024)
Rubric for Clinical Performance

Saad Fahad Alabbad

Student's name: ------------------------------------------------------ID# 2220005739.
------------------------Group 1.
#--------- Date:__________________
6 November 2023
Rating Scale /Criteria
Items Point
Excellent Very good Good Poor s
) 10-8) (7.5-6) (5.5-4) (3.5-0)
1. History-taking Elicits complete, relevant history, with Elicits complete history; relevant to the Missing some basic history, but Misses some basic history, which
skills strong, focused tracking of patient’s problems; completes basic omission, is not likely to lead to could lead to incomplete or incorrect
information relevant to patient database but misses some sharpness of missed diagnosis and needs identification of needs and diagnosis.
conditions and diagnoses, often focus or detail relevant to patient recognition.
beyond the basic database, and condition and diagnoses.
identifies all patients’ needs and
problems.
2. Initiate and Demonstrates ability to perform Demonstrates ability to perform Demonstrates good ability to perform Cannot demonstrate an ability to
Maintain previously learned skills with minimal previously learned skills. Requires previously learned skills, but requires perform previously learned skills.
therapeutic or no instructor assistance about moderate instructor assistance in maximum instructor assistance in about showing interest; using
relations with showing interest; use appropriate showing interest; using appropriate showing interest; using appropriate appropriate communication
patients. communication technique, deal with communication techniques, and dealing communication techniques, and techniques, and dealing with patient
patient needs and problems. with patient needs and problems. dealing with patient needs and needs and problems. May
problems. demonstrated unsafe patient care
about building a therapeutic
relationship with a patient.
3. Plan of care Student outlines a complete and Student outlines an effective care plan Plan of care loss of more than two The plan of care is incomplete, all
[Outlines effective plan of care for the selected for the selected patient, but misses one components or not relative to the components missing or not relative to
effective plan of patient) prioritizes Ng's diagnosis, or two components) prioritizes Ng's selected patient's condition prioritizes the selected patient's condition. )
care] develops individualized plans, and diagnosis, develops an individualized Ng diagnosis, develop an prioritizes Ng's diagnosis, develops
problems covering). plan, and problems covering). individualized plan, problems an individualized plan, and problems
covering). covering).
4. Verbalizes an Consistently demonstrates above- Demonstrates an average level of Consistently demonstrates a below- Consistently demonstrates a
understanding average knowledge and competence in knowledge and competence in average level of knowledge in dangerous and unsafe level of
1
 of the knowledge of medication and medication and treatment regimens for medications and treatment regimens knowledge in medications and
medications treatment regimens for the patient. the patient. for the patient. treatment regimens for the patient.
and treatment
regimen
5. Implementation Able to initiate all aspects of the Able to initiate three aspects of the Able to initiate two aspects of the Omits initiation of all aspects of the
of management treatment plan in the areas of treatment plan in the areas of treatment plan in the areas of treatment plan in the areas of
plan (diagnostic, therapeutic activities and (diagnostic, therapeutic activities, and (diagnostic, therapeutic activities, and (diagnostic, therapeutic activities,
patient education, follow-up) patient education, follow-up) patient education, follow-up) and patient education, follow-up)

Reports and documents findings, Reports and documents findings, Reports and documents findings, Demonstrates a dangerous level of
6. Documents and
including student PORTFOLIOS including student PORTFOLIOS including student PORTFOLIOS at a competence in reporting and
reports findings
appropriately at an above-average appropriately at an average level of below-average level of competence, documenting findings. Performance
appropriately.
level of competence, with minimal or competence, with a moderate amount with maximum amount of instructor is unsafe.
no instructor intervention. of instructor intervention. intervention.
7. Follow up on All the time follows up on the Most of the time Follows up on the Often she follows up on the Rarely follow up on instructor's
the instructor's instructor's suggestions and makes instructor's suggestions and makes instructor's suggestions and makes suggestions and makes
direction for improvements accordingly. improvements accordingly improvements accordingly. improvements accordingly
improving care.
8. Professional All the time maintains proper Most of the time demonstrates proper Often demonstrates proper grooming, Rarely maintain proper grooming,
grooming, grooming, all time shows punctuality grooming, punctuality, and assignment punctuality, submission of punctuality & assignment
Punctuality, in assignment submission, submission, mostly arrives on time, assignments with the maximum submission. All the time show late
and attendance Consistently arrives on time, and/or and/or notifies the instructor of amount of instructor intervention & submission, Consistently arrives late,
notifies the instructor of absence. absence. inconsistent with arriving on time and and does not notify the instructor.
notifying the instructor The Absence is unexcused.

9. Post- Clinical Completely formulates, relevant Data Completely formulates, relevant Data Missing some relevant Data R/T Missing main relevant Data R/T
Exam R/T patient’s health condition, R/T patient’s health condition, patient’s health condition, diagnoses, patient’s health condition, diagnoses,
diagnoses, and treatment plan. diagnoses, and treatment plan. and treatment plan. In-completely and treatment plan. In-completely
Effectively identifying & presenting Effectively identifying & presenting identifying patients’ problems, identifying patients’ problems,
all patients’ problems, setting the all patients’ problems, missing some missing to present some points R/T missing to present major points R/T
nursing care plan and management points R/T the nursing care plan and the nursing care plan and management the nursing care plan and
management management
Total
/90

Total clinical performance. = Actual marks out of 10 { } Instructor's Signature: --------------------------------------- Student's Signature: ------------------------