Name: Onipha Tappin Date: 24/11/13 Teacher: Sis Zac-Gore

Introduction

Table of Contents
Introduction Biographical Data Chief Complaint Current history. Past Medical and Surgical History Current Health Status.. Family History.. Psychosocial History.

Biographical Data
Name: A D Sex: Female D.O.B: 08/10/1980 Age: 33 Address: Freetown Village Tel: 560-0000 Religion: Moravian Race: Negro Next of Kin: HD Relationship: Mother

Subjective Data
Chief Complaint
No complaints

Current History
she was admitted to the hospital due to her unstable behaviours at home and her family viewing her as a danger to herself and others.

Past Medical and Surgical Health History

Medical: sickle cell trait drug induced psychotic behaviours Surgical: none

Current health status

Medications: zyprexia 10mg Diet: Full diet Physical Activity: Ambulates in the hospital corridors but does no specific exercise. Smoking: marijuana- 10 years Drinking: No drinking Routine check-up: Screenings: none

Family History
Mother has diabetes mellitus

Psychosocial History
Stress Management: She manages stress by smoking. Coping: She copes by smoking. Social Support: she has her family for support but she is an individual that doesnt like to share her problems. Level of education: she has a education level up to college where she went to a community college for 2 years Marital Status: single Children: 2 sons ages 13 and 4 years Occupation: security guard Salary bracket: $2000 per month Living Amenities; she lives in a 2 bedroom house she uses tank water there is no running water. Sewage disposal is done in the septic tank.

Head-to-Toe Assessment
Height: 163cm (54) B/P: 120/78 Pulse: 78 bpm Weight: 160lbs Temp: 98.4F Resp: 21 bpm

General appearance: AD is a 33year old black female, she articulates clearly, ambulates without difficulty. CNS: Alert and oriented to person, place and time. Thought coherent. Remote and recent memories intact. Cranial nerves ii through xii intact. Sensory; pin prick light touch intact. Able to identify objects.. no atrophy, weakness or tremors. No gait abnormalities. CVS: Heart sounds normal no murmurs or thrills present. apical and peripheral pulses strong and bounding. mucous membranes moist and pink. capillary refill brisk on return. Respiratory: Equal bilateral chest expansion. Breath sounds audible. Lungs field clear with no adventitious sounds. Diaphragmatic excursion equal bilaterally. Skin: Uniform in colour, warm, dry, intact, turgor good. Hair, normal distribution and texture, no pest inhabitants. Nails, no clubbing, biting present, no discolorations. Musculoskeletal: Colour distribution on extremities equal, no deformities or lesions.no tenderness. All peripheral pulses present and equal bilaterally. Full ROM present. No tenderness or weakness in joints. Muscle strength able to maintain flexion against resistance and without tenderness. GI: Flat, symmetric. Skin smooth with no lesions, scars or striae. Bowel sounds present, no bruits. Abdomen soft no masses or tenderness. GU: Genitals are clean with no abnormalities present.

Nursing Diagnosis Non-compliance with medication regimen related to behavioural changes evidenced by patients mother verbalizing complaints with patients behaviour.

Care Plan
Assessment Young woman admitted due to reports of disturbed behavioural changes, she is noncompliant with medication regimen. Nursing Diagnosis Noncompliance with medication regimen related to behavioural changes evidenced by patient being restless and combative. goal Patient will cease smoking with adequate teaching and counselling Interventions -ask the patient what is her reason for not complying with the medication regimen. to know her specific reasons for not taking the medications. -educate patient on the importance of taking medications. To aid in compliance. -provide measures to aid patient with coping with the side effects of medications. To better aid Outcome Criteria Patient has ceased smoking with teaching and counselling

compliance -ensure the patient receives prescribed medications as ordered. to. to prevent behavioural disturbances. - educate support persons on the importance aiding the client to take medications. this aids in compliance and offers support