HISTORY AND BIODATA OF THE PATIENT

1.IDENTIFICATION DATA

Name : Mrs. Devajyoti

Age : 24 years

Sex : Female

Father : Mr. Dhanaraja

Education : 12th stanndard

Marital status : Married

Occupation : Housewife

Religion : Hindu

Address : H-NO 28 Nalanda Nagar shree narayan shankar palace, Bangalore

Informant : Husband

Information : The information is reliable and adequate

2.PRESENTING CHIEF COMPLAINTS :

As per the patient’s complaints:

 Unable to remember
 Unable to recall recent events
 Suddenly found herself in new place
 Chronic headache

As per to Informant

 Going outside without information

 Not able to tell purpose for going outside
 Unable to recall why she went outside
3. HISTORY OF PRESENT ILLNESS

Mrs. Devajyoti, a 24 year old female patient was apparently normally before 1 1/2 year. Once she
went outside for shopping, but not returned home for two days, after when she came back, she
told that she went Mysore but not able to tell why she went. Aftter that four or five same
incidence happens when she went some new place but not able to recall how it happened. On
15.10.2018 she was admitted in Bhopal memorial hospital with a provisional diagnosis of
dissociative disorder. Finally, she diagnosed as dissociative fugue disorder and admitted in
female ward. Finally, she diagnosed as dissociative fugue disorder and admitted in female ward
for further investigation and treatment.

4. PAST PSYCHIATRIC AND MEDICAL HISTORY

No significant past psychiatricand medical history

5. FAMILY HISTORY

Male

Female

Patient

S.NO Name of Age/sex Relation Education Occupation Health

family with status
members patient
1. Mr. Dhanaraja 51y/Male Father 8th std Business Healthy
2. Mrs Mahesvari 48y/Female Mother Illiterate House wife Healthy
3. Ms. Urvasha 20y/Female Sister Student - Healthy
6. PERSONAL HISTORY

A. Perinatal history
Mrs. Devajyoti was delivered as full term normal vaginal delivery. She cried
immediately after birth and there was no postnatal complication like cyanosis,
convulsions and jaundice.

B. Childhood history
The primary caregiver was the patient’s mother. Weaning started at the age of 4-6 months
and all developmental milestones was achieved at appropriate age period. There was no
behavior and emotional problems like temper tantrums, head banging, nail biting and
enuresis except thumb sucking and that behavior changed at the age of one year

C. Educational history
Education was started at the age of 3 years. She was average in academic performance
and had good relationship with teachers and peer.

D. Play history
She used to play with both sex peer group and had good relationship with peers.

E. Emotional problem during adolescence

There is no significant history of emotional problems like running away from home,
aggressiveness and assault.

F. Puberty
Secondary sexual characteristics appeared at the age of 14 years. She did not have
anxious mood regarding sexual changes. .

G. Occupational history
Mrs. Devajyoti is a housewife.
H. Premorbid personality
 Interpersonal relationship: Introvert
 Use of leisure time: Watching T.V
 Predominant mood: Mood alteration
 Attitude to self and others: Self – appraisal of abilities and behaving normlly with
others.
 Religious beliefs and moral attitudes: Having faith on religious and participating in
religious activity
 Habits: He is not having any habit like smoking and drinking.
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.

5. RANGE OF MOTION

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

6. LYMPH NODES

No inflammation or swollen lymph nodes found

7. BREASTS

INSPECTION

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

8. PELVIC EXAMINATION

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

9. 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

NURSING MANAGEMENT

Nursing diagnosis

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

autonomic response evidenced by poor impulse control
 Ineffective coping related to inability to form a valid appraisal of the stressor evidenced
by ineffective expression of feelings.
 Self-care deficit related to impaired ability to complete bathing/hygiene activities for
oneself evidenced by poor personal hygiene.
 Ineffective health maintenance related to inability to identify, manage and seek out help
to maintain health evidenced by poor hygiene.
 Fear related to response to perceived threat that is consciously recognized as a danger.
HEALTH EDUCATION

I Patient teaching on discharge plan

 Instruct the patient to inform while going out

 Instruct patient to carry identity card
 Advise the patient to take bath daily
 Advise to change cloths daily
 Encourage social interaction
 Improve the self-care needs (personal hygiene) independently
 Sleep and hygiene technniques.
 Instruct to use relaxation when getting aggressive
 Taught about the positive coping methods
 Advised to spend more time with family
 Advice the patient for regular checks up and follows up

II Family teaching on discharge plan

 Family’s to use alternative coping methods.

 Educated regarding medication- dosage and side effects of the medication
 Advise to spend more time with patient

SUMMARY

Mrs. Devajyoti brought to female psychiatric open ward on 15.10.2018 with the complaints of
loss of memory, unable to recallrecent events, suddenly found herself in new place, chronic
headache, going outside without information, not able to tell purpose for going outside, unable to
recall why she went outside. On 15.10.2018 she was admitted in Bhopal memorial hospital with
a provisional diagnosis of dissociative disorder. Finally, she diagnosed as dissociative fugue
disorder and admitted in female ward for further investigation and treatment. I have tken this
case for my case study and given four days care with counseling and health education.
Assessment Nursing diagnosis Goals Intervention Implementation Evaluation
Subject Anxiety related to TTo reduce  Remain with the client  Remained with the Anxiety
data: vague uneasy anxiety at all times when levels client at all times reduced
Patient feeling of evidenced by of anxiety are high when levels of evidenced by
complains of discomfort or dread client will anxiety are high the client
feeling of accompanied by an respond to  Move the client to a  Moved the client to responded to
discomfort. autonomic response relaxation quiet area with minimal a quiet area with relaxation
evidenced by poor techniques or decreased stimuli. minimal or techniques
impulse control with a decreased stimuli. with a
decreased  Remain calm in your  Remained calm in decreased
anxiety level approach to the client your approach to the level of
client anxiety.
 Use short, simple, and  Used short, simple,
clear statements. and clear statements.
 Avoid asking or forcing  Avoided asking or
the client to make forcing the client to
choices. make choices.
 Encourage the client’s  Encouraged the
participation in client’s participation
relaxation exercises. in relaxation
Objective exercises.
 Teach the client to use  Taught the client to
data: relaxation techniques
Patient use relaxation
expresses techniques
 Help the client see mild  Help the client see
restlessness anxiety
and mild anxiety
palpitations

Assessment Nursing Diagnosis Goals Intervention Implementation Evaluation

Subjective Ineffective coping To maintain  Make observations to  Made observations Maintained
Data: related to inability effective the client about her to the client about effective
The patient to form a valid coping anxious behavior. her anxious coping
says that he appraisal of the evidenced by behavior. evidenced by
does not stressor evidenced client will  Help the client  Help the client client
want to live. by ineffective participate in recognize early signs of recongnize early participated in
expression of realistic her anxious behavior signs of her anxious realistic
feelings. discussion of behavior. discussion of
problem  During the times the  During the times the problem
client is relatively calm, client is relatively
explore together ways in calm, explore
which he or she can deal together ways in
with stress and anxiety. which he or she can
deal with stress and
anxiety.
 Encourage verbal  Encouraged verbal
expresssion of feelings. expression of
feelings.
 Teach the client a step-  Taught the client a
by-step approach to step-by-step
solving problems approach to solving
Objective roblems
 Suport the client’s
data:  Supported the
positive actions
She looks client’s positive
depressed. actions
 Encourage the client to
evaluate the success of  Encouraged the
the chosen alternative. client to evaluate the
success of the
chosen alternative.

Assessment Nursing Goals Inntervention Implementation Evaluation

Diagnosis
Subjective Self-care deficit Establish an  Be alert to client’s  Alert to the client’s Established
data: The related to adequate physical needs physical needs an adequate
patient’s impaired ability balance of balance of
relative said to complete rest, sleep,  Obseve the client’s  Obsserved the client’s rest, sleep
he does not bathing/hygiene and activity pattern of food and fluid pattern of food and fluid and activity
maintain activities for evidenced by intake; you may need to intake; you may need to evidenced
personal oneself evidenced the client will monitor and record monitor and record by the client
hygiene. by poor personal complete intake, output, and daily intake, output, and daily will
hygiene daily tasks weight weight complete
with minimal daily tasks
assistance  Monitor the client’s  Monitored the client’s with
elimination patterns elimination patterns minimal
assistance.
 Explain any task in  Explained any task in
short, simple steps short, simple steps

 Using clear, direct  Used clear, direct

sentences, instruct the
client to do one part of
the task at a time
Objective
data: He  Tell the client your
looks untidy expectations directly.
and Do not ask the client to
unkempt choose unnecessarily
 Allow the client ample
time to complete any
task.
sentences, instruct the
client to do one part of
the task at a time
 Told the client your
expectations directly.
Do not ask the client to
choose unnecessarily.
 Allowed the client
ample time to completee
any task

Assessment Nursing Goals Intervention Implementation Evaluation

diagnosis
Subjective Ineffective Complete  If the client has delusions  The client has delusions Completed
data: health necessary that prevent or limit rest, that prevent or limit rest, necessary
Patient says maintenance daily sleep, or food or fluid sleep, or flood or fluid daily
that he does related to activities intake, it is necessary to intake, it is necessary to activities
not have inability to with institute measures that institute measures that with
interest in identify, manage minimal deeal directly with deal directly with health. minimal
doing any and seek out help assistance physical health. assistance.
activities. to maintain
health evidenced  If the client thinks that his  The client thinks that his
by poor hygiene. or her food is poisoned or or her food is poisoned or
that he or she is not that he is not worthy of
worthy of food, it may be food, it is necessary to
necessary to alter routines. alter routines.
Objective  The client is too
 If the client is too
data: ssuspicious to sleep, try
suspicious to sleep, try to
Patient does to allow the client to
allow the client to choose
not take care choose a place and time
a place and time in which
of self. The in which he feel most
he or she will feel most
does not comfortable sleeping.
comfortable sleeping.
sleep Sedatives needed may be
Sedatives as needed may
properly. indicated
be indicated

Assessment Nursing Goals Intervention Implementation Evaluation

dignosis
Subjective Fear related Decrease  Allow the client to  Allowed the client to Decreased
data: the to response his fear and express feelings openly. express feeling openly. avoidance
patient to perceived to make behaviors
complains threat that is him slight  Teach the client and  Taught the client and evidenced by
that he is consciously comfortable family or significant family or significant client verbalize
afraid of recognized others about phobic others about phobic feeling of fear
dangers and as a danger. rections. reactions. and discomfort
certain
stimuli.  Reassure the client that  Reassured the client the
she can learn to decrease she can learn to decrease
the anxiety attacks. the anxiety attacks.

 Assist the client to  Assist the client to

distinquish between the distinquish between the
phobic trigger and those phobic trigger and those
Objective
problems related to problems related to
data: He
avoidance behaviors that avoidance behaviors.
looks
are interfering with daily
anxious and  Instructed the client in
life.
fearful. progrressive relaxation
 Instruct the client in
progressive relaxation until he or she is
techniques. comfortable and
 Encourage the client to successful.
practice relaxation until
he or she is comfort and
successful.

THEORY APPLICATION

King’s theory:

King’s theory of goal attainment encompasses three broad interlocking;

-Open system,

-The personal and interpersonal

-Social system

The personal system and social system influence the quality of care and the major elements in the goal attainment are contained in the
interpersonal system. In these system two or more persons come together under the guidance if health care organization to promote an
optimal state of health.

The major concepts are –

 Interaction
 Perception
 Communication
 Transaction
 Roles
 Stress
 Growth and development
 Time and space

Transaction – try to resolve delusion

Role Stress environmental stresses

- Use of coping methods

- Communication - Educational experience
- Therapies - Socioeconomic status
 - Solve the problems
- Concerns regarding patient
- IPR
- Aware of course awareness
- Interaction

Space Time

Kings Goal Attainment Theory