HISTORY AND BIODATA OF THE PATIENT

1. IDENTIFICATION DATA

Name : Mrs. Pooja raikwar

Age : 34 years

Sex : Female

Spouse : Mr. Rakesh raikwar

Education : B.Tech.

Marital status : Married

Occupation : Receptionist at private company

Religion : Hindu

Address : House No- 154, Kamal nagar, Devas

Informant : Patient’s husband

Information : The information is reliable and adequate

2.PRESENTING CHIEF COMPLAINTS :

As per the patient’s husband:

 Patient has anxiety (ghabrahat)

 Patient has disturbances in sleep.
 Patient has decreased appetite.

3. HISTORY OF PRESENT ILLNESS

Mode of onset : Insidious

Course : Episodic
Intensity : Same

Precipitating factors : No

Description of the present illness; A 34 year old patient, Pooja, was brought to psychiatric
OPD with complaints of ‘ghabrahat’, disturbed sleep and decreased appetite. Ghabrahat was
present for 15-20 mins. The patient could feel her heart beating fast at that time. She would start
sweating excessively and felt that she could not speak anything at that time. Her mouth used to
become dry. the patient used to feel that she might die during the ghabraht.

Such episodes of ghabrahat occurred several times in a day. The patient felt afraid and became
apprehensive in between the attacks.

4. PAST PSYCHIATRIC AND MEDICAL HISTORY

Patient had similar episodes in March, 2017. She was admitted in Bhopal Memorial HOSPITAL
AND Research Centre. She was treated with Fluoxetine 20mg/day, Venlafexine 70mg/day and
clonazipine 1mg/day. The patient had responded well to the treatment but discontinued the
treatment three months ago.

No past history of any other mental illness or any relevant physical illness.

5. FAMILY HISTORY

Mrs. Pooja Mr. Rakesh

Patient Husband
S.NO Name of Age/sex Relation Education Occupation Health
family with status
members patient
1. Mr. Rakesh 45y/Male Husband B.Com. Business Healthy
2. Vandana 10y/Female Daughter 5th std Student Healthy
3. Vishal 8y/Male Son 3thstd Student Healthy

PERSONAL HISTORY

A. Perinatal history
 She was born by normal, full term delivery by a local Dai

B. Childhood history
 The primary caregiver was the patient’s mother
 Feeding and weaning were appropriately done.
 Developmental milestones were achieved at appropriate age.

C. Educational history
 Age at beginning of formal education: 4 years
 Academic performance: Below average
 School phobia: No
 Reason for termination of studies: Lack of interest and early marriage

D. Play history
 She had good relationship with playmates.

E. Emotional problem during adolescence

 Patient was shy in the childhood and had limited friends.

F. Puberty
  Age at appearance of secondary sexual characteristics: 12 years
 Anxiety related to puberty changes: Yes
 Age at menarche: 14 years
 Regularity of cycle, duration of flow: Was regular untill recently, when it became
irregular.

G. Obstetrical history
 LMP: 10. 2.2016
 Number of children: 2
 Any abnormalities associated with pregnancy: No
 Termination of pregnancy: No

H. Occupational history
 Patient is working in a private company as a receptionist .

I. Sexual and Marital history

 Type of marriage: Arranged
 Duration of marriage: 11 years
 Interpersonal and sexual relations: Satisfactory
 Extramarital relationships: No

J. Premorbid personality
 Patient had problems with her brother. Till now, she doesn’t talk to her brothers.
 She used to stitch clothes during her leisure time.
 The eating pattern, elimination and sleep patterns were normal.
 Patient does not use any drugs, tobacco or alcohol..

PHYSICAL EXAMINATION

GENERAL EXAMINATION

Vital Signs
Temperature : 36.2 degree celsius

Pulse : 76 beats/minute

Respiration : 28 breaths/minute

Blood Pressure : 120/80 mm of Hg

1. CARDIOVASCULAR SYSTEM AND PERIPHERAL PULSATIONS

INSPECTION

No lifts or heaves

PALPATION

No palpable pulsation over the aortic pulmonic and mitral valves. Apical pulsation can be felt.

PERCUSSION

No cardiac dullness found.

AUSCULTATION

S1 and S2 can be heard, no abnormal heard sounds, Cardiac rate is 76 bpm.

PERIPHERAL PULSATIONS

Peripheral pulsations can be felt

2. RESPIRATORY SYSTEM

INSPECTION

The shape is elliptical, moves symmetrically, no chest retractions found, no scoliosis / kyphosis /
lordosis seen.

PALPATION

No lumps or masses found no areas of tenderness seen. Tactile fremitus checked no evidence of
consolidation, obstructions of thickening of the pleura.
PERCUSSION

No abnormal sounds like hyper resonance, resonance is found

AUSCULTATION

No abnormal lung sounds found like wheezes, crackles.

3. ABDOMEN

INSPECTION

Skin color is uniform, no lesions, no pigmentation, and no scars.

AUSCULTATION

Hypoactive sounds found

PERCUSSION

No dullness is found

PERCUSSION FOR LIVER

No dullness is found

RENAL PERCUSSION

Normal

PALPATION

No tenderness or masses present

4. MUSCULOSKELETAL SYSTEM

Posture of the patient is straight gait is normal.

RANGE OF MOTION
Range of motion of neck, spine, upper and lower extremities, joints is possible in the patient

5. LYMPH NODES

No inflammation or swollen lymph nodes found

6. BREASTS

INSPECTION

Symmetrical, nipples are round and everted, no orange peel skin is seen, veins visible, no
retraction or dimpling.

7.PELVIC EXAMINATION

Patient have no discharges per vaginally, no redness, no signs of infection present.

8. OTHERS SIGNS

No other signs found

MENTAL STATUS EXAMINATION

A.GENERAL APPEARANCE AND BEHAVIOR

Appearance: Looks accordingly her age

Facial expression : Blunted

Level of grooming : Normally dressed.

Level of consciousness : Patient is fully conscious and alert

Mode of entry : Patient was brought by persuasion.

Behavior : Normal

Cooperativeness : Patient is adequately cooperative

Eye- to –eye contact : Eye contact is easily maintained

Psychomotor activity : Psychomotor activity is normal.

Rapport : Spontaneously established

Gesturing : Normal

Posturing : No stereotypic movements or catatonia

Hallucinatory behavior :No

B.SPEECH

Initiation : Speaks when spoken to

Reaction time : Normal

Rate : Normal rate of speech

Productivity : Elaborate replies

Volume : Normal

Tone : Normal variations are present

Relevance : Sometimes off target

Stream : There is no circumstantiality or tangentiality

C. MOOD AND AFFECT

Subjective : Patient says that she is happy and is feeling good.

Objective : Patient looks cheerful when spoken but remains blunt when silent.

Appropriateness : Affect is appropriate.

D. THOUGHT

Stream: the flow of thought is normal

Form: Normal, there is no tangentiality or circumstantiality

Content: Patient does not have any delusions. Patient has episodes of panic anxiety, periodically
which exists for 15-20 minutes.

E.PERCEPTION

No perceptual abnormality present.

F. COGNITIVE FUNCTION

Consciousness : Conscious

Orientation, attention, concentration, memory, intelligence, abstraction, judgment etc could not
be elicited because patient does not respond. Patient continues to lie down in the bed.

G. INSIGHT

Patient completely denies his illness.

THEORY APPPLICATION

Hildegard E. Peplau (September 1, 1909 – March 17 , 1999) was an American nurse and the
first published nursing theorist since Florence Nightingale and created the middle – range
nursing theory of interpersonal relations, which helped to revolutionize the scholarly work of
nurses. As a primary contributor to mental health law reform, she led the way towards humane
treatment of patients with behavior and personality disorders.

Peplau’s Interpersonal theory:

The core of Peplau’s approach is interpersonal relations. The theory includes the concept such as
communication, roles and growth and development. Communication as a problem solving
process whereby the nurse and client collaborate to meet the clients need. The nurse may assume
the roles of counselor, leader, resource, surrogate, and teacher. These roles are designed to lead
to growth and development.

Interpersonal theory and nursing process

 Both are sequential and focus on therapeutic relationship

 Both use problem solving techniques for the nurse and patient to collaborate on, with the
end purpose of meeting the patients needs

Assessment Orientation
 Data collection and analysis (continuous)  Non continouos data collection
 May not be a felt need  Felt need
 Define needs
Nursing diagnosis Identification
 Planning  Interdependent goal setting
 Mutually set goals
Implementation Exploitation
 Plans initiated towards achievement of  Patient actively seeking and drawing
mutually set goals help
 May be accomplished by patient, nurse or  Patient initiated
 family
Evaluation Resolution
 Based on mutually expected behaviors  Occurs after other phases are
 May led to termination and initiation of new completed successfully
plans  Leads to termination

Health Education

 Encourage social interaction

 Improve the self care needs (personal hygiene) independently
 Sleep hygiene techniques
 Family’s to use alternative coping methods
 Prevention of violent behavior
 Taught about the positive coping methods
 Prevention of self harm and others.
 Advised to spend more time with family when he feels anxious
 Educated the patient and family members regarding medication-dosage and side effects
of the medication
 Advice the patient for regular checks up and follows up
 Advice the start the work gradually. Initially start with fulfill his own needs and home
works.

Summary

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a
number of different things. People with GAD may anticipate disaster and may be overly
concerned about money, health, family, work, or other issues. Individuals with GAD find it
difficult to control their worry. They may worry more than seems warranted about actual events
or may expect the worst even when there is no apparent reason for concern.  
NURSING DIAGNOSIS

1. Anxiety related to vague uneasy feeling of discomfort or dread accompanied by an

autonomic response evidenced by poor impulse control
2. Social isolation related to panic anxiety, evidenced by withdrawal, expression of feelings
of rejection of aloneness imposed by others.
3. Self-care deficit related to withdrawal, panic anxiety, perceptual or cognitive impairment,
evidenced by difficulty in carrying out tasks associated with hygiene, dressing, grooming,
eating and toileting.
4. Self-esteem disturbance related to unmet dependency needs, lack of positive feedback,
unrealistic self-expectations evidenced by sensitivity to criticism, negative and
pessimistic outlook.
5. Exaggerated fear related to unknown stimuli.
6. Sleep pattern disturbance related to emotional disturbances.
7. Impaired social interaction related to effects of behavior and action on forming and
maintaining relationship.
8. Altered spiritual distress, deviation, pain related to inability to deal with anxiety
9. Knowledge deficit regarding psychiatric illness and treatment.
BIBLIOGRAPHY

1. Townsend. M, (2007), “Psychiatric Mental Health Nursing”, Jaypee brothers, New Delhi
2. Doenges M.E. et al., (1995), “Psychiatric Care Plans Guidelines for Planning and
documenting Client Care”, 2nd ed. F.A. Davis Company, Philadelphia, PA
3. Ahuja.N, (2006),”a Short Text Book of Psychiatry”, Jaypee brothers, New Delhi
4. Sreevani. R, (2008), “ A Guide to Mental Health and Psychiatric Nursing”, Jaypee
Brothers, New Delhi
 MAR BASELIOS COLLEGE OF NURSING
BHOPAL

SUBJECT: MENTAL HEALTH (PSYCHIATRIC)

NURSING

NURSING CARE PLAN ON

“DEPRESSION”

SUBMITTED TO, SUBMITTED BY,

Mrs. Sini Shaji Ms. Sherin Joseph
Professor M.Sc. Nursing II Year
Date: 11/10/2018