Aaron E.

Mauricio
BSN-1A

Assessment
Berna make a visit in a nearby Clinic on her town. She's suffering lack of concentration for
almost two weeks. He fill-up the check-up form that the nurse on staff gave her. The nurse takes
her temperature, heart rate, blood pressure, and weight. The nurse then ask john lots of questions
about how he's been feeling lately. The nurse then writes notes about berna's responses when she
answers she's been having difficulty remembering past events and lack of focus. Berna gave her
past medical history to her attending nurse and she has a mental disorder. Her blood sanple was
taken by the nurse when she visited her doctor.
Diagnosis
The nurse observes berna's symptoms and writes that her blood pressure is high. She consider
that berna experienced anxiety and obesity since her blood pressure are both high. The nurse then
comes to her conclusion that berna is experiencing Bipolar Syndrome, known as a mental illness
marked by extreme shifts in mood. Berna's medical history confirms the nurses' conclusion.
Nangangamba rin ang nurse na baka lumala ang sakit ni berna at makaapekto ito sa mga
nakapaligid sa kanya.

Planning
Berna returns to the clinic after one week for her follow-up check up. Berna enters on a room
and sit in front of the nurse and the nurse explains berna's blood pressure and heart rate. She
suggest that berna can have psychiatry check ups every week so that it cannot get worst. She also
need to stop pressuring herself and needs to sleep at least 7 hours a day. The nurse also tells
berna to stop staying on her house and try to communicate with others. Berna agrees on the nurse
suggestion, and they set up an appointment for a check up with the psychiatrist one and a half
weeks later. The nurse reminds berna to call if there are changes in her condition, or if it gets
worse.

Implementation
Sinunod ni berna ang utos ng nurse na magpacheck up sa psychiatric doctor. After one and a half
week, bumalik si berna sa nurse at dumadaing na kesyo may nagbago sa kanya. Medyo gumaan
na yung pakiramdam niya pero inaantok siya palagi after magtake ng medication. Ipinaliwanag
ng nurse kay berna na ang gamot ang nag cause nung pagkaantok niya. She advices berna to
drink energy drink and avoid stressful things. Berna continues taking her meds, two times a
week. After two weeks, she returns to the clinic for her follow up appointment.
Evaluation
Pag balik ni Berna, tinanong siya ng nurse ng maraming tanong tungkol sa mga naramdaman
niya after one and a half week. Nag reply si berna na medyo maganda na daw ang pakiramdam
niya at hindi na siya gaanong moody. After a week, may mga nakilala na rin siyang ibang tao
galing sa same clinic na may mental disorder. The nurse marks “patient's condition Improved”
on her official medical records and congratulates berna on her well being. The nurse advices john
to remain on the medication for atleast, one more month and to continue her lifestyle.