Case
Index Page | Subject | 3 | Identification data | 3 | Socioeconomic status and living arrangement | 3 | Current problems and chief complaint | 4 | History of the psychiatric illness and admission | 4,5 | Personal history | 5 | Family history | 6 | Medical History | 6-8 | Life value | 9 | Social habits and living patterns | 9 | General appearance and physical characteristics | 9 | Speech | 9 | Psychomotor activity | 9 | Anxiety level and its effect on client | 11 | Mental status Examination | 12 | Present treatment | 12 | Other examinations | 12 | Attitude toward interviewer | 13 | Psychiatric Diagnosis: DMS IV | 14 | Problems and nursing diagnosis | 15 | Nursing care plan | 22 | References |
Week of experience: 9th wk students: Maisa, Sama& Fida
Date of admission: 7\10\2011 Initials: A.G.S
Psychiatric Dx: Schizo Affective disorder ward: rehabilitation
Instructors name: Mrs. Nadia Sbeeh & Mr Abdallh Al wawy
1- Identification:
Age: 46 yrs old Sex: female Residence: Dr. Ivonah
Education: 11th grade religion: Christian Marital status: single 2- Socioeconomic status and living arrangements:
A.G.S is a 46yr old single female she used to live with her parents and one sister in Bethlehem, at a building in the second floor; their house consists of 3 rooms, one living room, one gust’s room, a kitchen and a bathroom. The air in the area is unclean as she mentioned. There are permanent electricity, water and sanitation services, not far away from the main road; stairs within the building are with balustrades. The general economic status is good her father is a carpenter and her mother was a translator,
Week of experience: 9th wk students: Maisa, Sama& Fida
Date of admission: 7\10\2011 Initials: A.G.S
Psychiatric Dx: Schizo Affective disorder ward: rehabilitation
Instructors name: Mrs. Nadia Sbeeh & Mr Abdallh Al wawy
1- Identification:
Age: 46 yrs old Sex: female Residence: Dr. Ivonah
Education: 11th grade religion: Christian Marital status: single 2- Socioeconomic status and living arrangements:
A.G.S is a 46yr old single female she used to live with her parents and one sister in Bethlehem, at a building in the second floor; their house consists of 3 rooms, one living room, one gust’s room, a kitchen and a bathroom. The air in the area is unclean as she mentioned. There are permanent electricity, water and sanitation services, not far away from the main road; stairs within the building are with balustrades. The general economic status is good her father is a carpenter and her mother was a translator,
References: 1) All-In-One care planning resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans, Second edition. 2) Katherine M.Fortinash, Psychiatric Nursing Care Plan, 1991 by Mosby. 3) Patient and Patient file.