COLEGIO SAN AGUSTIN - BACOLOD

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 - 2471 Local 162
Email Address: csab.chap@gmail.com

PATIENT’S NAME: PATIENT A PATIENT’S AGE AND SEX: 43, F

CHIEF COMPLAINTS: ATTENDING PHYSICIAN: DR. A

GROUP AND SECTION: GROUP 12 - BSN2C AREA OF EXPOSURE: BQMH

DATE OF EXPOSURE: April 1-4, 2024 CLINICAL INSTRUCTOR: Jocelyn Ortaliz, MN, RN

PROBLEM LIST

CUES PROBLEMS PRIORITY PHYSIOLOGIC BEHAVIORAL

SUBJECTIVE PROBLEM 1
ACTUAL POTENTIAL ACTUAL POTENTIAL
The patient verbalized: Agitation Ineffective sleeping and
“nahidlaw nako saakon bata” Confusion eating pattern
Mood instability Disturbed sleep Risk for Injury Acute Confusion Risk for Social
Pattern related related to sleep related to Isolation
“ngaa gaka tabo ni saakon” Anxiety
delusion to R/T deprivation, as inadequate sleep related to
Folks verbalized: “waay sa postpartum evidenced by as evidenced by disrupted sleep
Claims of feeling psychosis with altered level of disorientation, patterns, as
katulog 3 kaadlaw bag-o siya
weak and tired depression as consciousness, impaired evidenced by
naadmit, kapoy pa guro kag
evidenced by slowed reaction decision-making, decreased
gutom kay ga prcess siya sa
bill sang bata ya nga na Ineffective sleeping difficulty falling times, and and mistaking social
pattern asleep, frequent impaired the nurse for her interactions,
cardiac arrest”
awakenings, decision-making, daughter. withdrawal
“gina tawag ya ang iban nga Loss of appetite and overall increasing the from social
tawo bata niya” Stress disturbed sleep. risk of accidents activities, and
or falls. potential
“gulpi lang siya nag waras- misunderstandi
waras kag daw indi withdrawn ngs in social
kapahimuyong bala haw” interactions.

“daw indi gid ni sa ya ma Ineffective Risk for Self-Care Risk for

sturya tarong sang isa PROBLEM 2 Eating Pattern Imbalanced Deficit: Feeding Impaired Body
kaadlaw, subong mayo kay ga Loss of appetite related to R/T Nutrition: Less related to loss of Image related
sabat na siya” postpartum than Body appetite, no will to anticipated
psychosis as Requirements to eat, unable to changes in
“subong tuyo lang siya pirmi evidenced by related to prepare meals for body weight or
kag ga palang luya” decreased postpartum herself. shape as
appetite, psychosis, as evidenced by
OBJECTIVE skipping meals, evidenced by expressing
and inadequate decreased worries or
-Behavioural changes notes intake of food. appetite and fears about
-Irritability noted skipping meals, changes in
-withdrawn to others placing the appearance
-confusion noted, patient patient at risk for due to altered
called the nurse “Lyka” inadequate eating habits.
reffering to her daughter nutrient intake
and weight loss.
Vital Signs

Blood Pressure:
130/900mmHg

Heart Rate: 78 bpm

Respiratory Rate (at rest): 23

cpm

Temperature: 36.1°C

CHIEF COMPLAINT/
MEDICAL HISTORY:

• Patient presents agitatied

• Two days prior to
admission, patient had
sudden onset of behavioral
changes and inability to
sleep, loss of appetite.
• A day prior to admission,
patient became agitated
and combative
• Patient has a history of
high blood pressure

MEDICATIONS

 Olanzapine 10mg
1tab, ODHS
 Rivotril 20mg ¼ tab
ODHS
 Aripiprazole 10mg ½
tab ODPC
 Carvedilol 25mg
1tab, OD
 Rosuvastatin 10mg
1tab, OD
 Trimetazidine 35mg
1tab, BID
 Kalium durule 1tab,
BID
 Esatalopram 10mg
1tab, ODHS
 Citicoline 1gm IVTT,
Q12