You are on page 1of 9

City University of Pasay College of Nursing and School of Midwifery

Psychodynamics
Submitted By : Cassey Charlotte E. Dagani Submitted to : Ms. Maria Enrica Dela Torre, RN

GENERAL DATA

Mr. J.E.D lives in Blk 30 Lt 35 Pacific Woods, Imus, Cavite. He is 17 years old. He is Filipino, single and currently a 1st year college student. His past history includes chickenpox, measles and mumps. He had past injuries like broken arm, legs sprains which he acquired from playing basketball. He was never been hospitalized. He has no allergies known and no medications taken. He has complete vaccination. His family health history includes diabetes and hypertension on both father and mother side.

PHYSICAL ASSESSMENT

BODY PARTS

TECHNIQUES

NORMAL FINDINGS

Head

Inspection

Palpation

Ears

Inspection

Palpation Eyes Inspection

The scalp is white, clean from dandruff, masses, and lumps. The hair is black, thick and evenly distributed. Shiny and free from any infestation such as pediculosis. The face is oval in shape, symmetrical, the facial expression is depends on the mood or feelings of the patient, and there are no any involuntary movements. The skull is proportional to the size of the body, round and symmetrical. There are no any areas of tenderness. The ears are parallel, symmetrical, proportional to the size of the head, bean shaped, and the helix is in line to the outer cantus of the eye, the skin is same color as the surrounding area. The ear canal is pinkish, clean, with scant amount of cerumen. The patient was able to hear whisper spoken 2 feet away. The ears have a firm cartilage. The eyes are parallel, symmetrical, none protruding, with scant amount of secretion. Both eyes are black. The eyebrows are black, thick can raise lower eyebrows symmetrically .The eyelashes are also black and evenly distributed and turned outward. The eyelids cover a small portion of the iris and the cornea and the sclera when the eyes are open. When the are

Palpation Nose Inspection

closed it meet completely. The iris are proportional to the size of the eye , round and black. The pupils are almost the size of the iris , it constrict with increasing light and accommodation. The eye was able to moves in full range of motion. The patient was able read the snellen s chart within 20 feet. The patient was also able to see 60 degree superiorly , 90 degrees temporally and 70 degrees inferiorly. No palpable masses. The nose is in the midline, symmetrical and patent. The internal nares are clean, pinkish with few cilia. The septum is straight.

Mouth

Inspection

Tongue is in midline. It is pink in color, with no deviation. Uvula is in midline, smooth and pink to red in color. It moves upward and inward as the patient says ah . Dental carries are present. There s a presence of gag reflex.

Neck Range of motion

Inspection

The neck is proportional to the size of the body and head, symmetrical and straight Freely movable without difficulty.

Muscular strength

(chin to chest , ear to shoulder) Inspection (sternocleidom astoid) (trapezius muscle) Palpation

Symmetrical and able to resist applied force.

Able to resist applied force There is no palpable lumps, masses , or areas of tenderness

Chest and lungs

Inspection

Palpation

The chest contour is symmetrical and the chest is twice as wide as deep. The spine is straight. Posteriorly the ribs tend to slope across and down. There is no bulging or retraction of intercostals spaces during breathing. The chest wall moves symmetrically. There are no palpable lumps, masses, and there are no areas of tenderness.

(chest excursion) (tactile fremitus) Auscultation


Cardiovascular

The examiner s thumb separate approximately 3-5cm during excursion. The vibrations are prominent over the areas near the bronchi it increases. The vibrations are strongest between the first and second ribs. No adventitious sound heard. There is no visible pulsation on aortic, pulmonic and tricuspid valve. The two heart sounds are audible in all areas but loudest at apical area. Cardiac rate range 85 beats/minute.

Inspection and palpation Auscultation

MUSCULOSKELETAL SYSTEM TESTING AND GRADING MUSCLE STRENGTH

MUSCLES

FINDINGS . Able to resist the applied force. Both ankles and feet are able to resist the applied force. Skeleton are in normal structure. No areas of tenderness.

Sternocleidomastoid, trapezius, biceps, triceps, wrist and finger muscle, grip strength, hip muscle, hip abduction, hip adduction, hamstrings. Muscles of the ankles and feet.

Bones Inspection and palpation

Joints Palpation

No presence of tenderness and swelling.

NEUROLOGICAL SYSTEM Patient is oriented with person, time and place.

Reflexes Biceps Triceps Patellar Achilles Plantar Cranial nerves CN I (Olfactory) CN II (Optic) CN III (Oculomotor)

Findings Slight flexion of arms at elbow Slight extension of arms at elbow Extension of lower leg Plantar flexion of the foot Plantar flexion of the right toes. Findings The patient was able to identify the smell of the object given to her. The patient was able to read without difficulty. The patient was able to move the eyes on the six cardinal movements without moving body. The patient was able to see the object on her periphery without moving the body. The patient was able to clench teeth, open jaw , extend and flex chin , identify the object for light and sharp touch. The patient s pupil constrict as the object gets near and dilates as the object moves away. The patient was able to raise eyebrows/frown/show teeth/smile/puff cheek. The patient was able to repeat whispered words 2 feet away from her. There is no hoarseness of the voice and can moves tongue. The palate and uvula move upward as the patient s say ah . The patient was able to resist the applied force on her shoulder. The patient was able to move the tongue freely.

CN IV (Trochlear) CN V ( Trigeminal)

CN VI (Abducens)

CN VII ( Facial )

CN VIII (Acoustic) CN IX (Glossopharyngeal) CN X ( Vagus ) CN XI ( Spinal accessory)

CN XII ( Hypoglossal)

FUNCTIONAL HEALTH PATTERN

Health Perception and Health Management Pattern: He defines health as absence of illness and has a sound physical and mental health. He keeps himself physically fit by being active and playing sports like basketball and jogging or walking during the afternoon or if he is free. He develops his mental capacities by meditating, reading a variety of articles and playing mind games like chess and scrabble. He only visits a dentist whenever he needs to c. He first treats himself if he is ill then seeks for medical consultation if the condition worsens.He also visits manghihilot if he suffers from injuries like leg sprain. Nutritional and Metabolic Pattern: He eats 4 times a day during school days and 3 times when there are no classes. His common diet includes rice, chicken, fish,pork, beef, leafy vegetables and lots of water. He does not take any food supplements. He tries to limit himself from eating junk and street foods even with caffeinated drinks. His favorite food includes those lutong bahay of her mother. He has no complaints about eating. He has a hearty appetite and could eat more but tries not to overeat. He drinks about 10 glasses of water everyday. Elimination Pattern: His bowel movement is twice a day. Its characteristic is soft and there is no blood. He does not have any problem in eliminating. He has no rituals before eliminating and does not need laxatives. He had experience diarrhea and constipation when he was young. He urinates 4-5 times a day. It is colorless but sometimes it is color yellow. He does not report any discomfort when urinating. His perspiration is hard to stop when it starts. Activity-exercise Pattern: He is very active. His daily routine when there are no classes involves doing house chores, walking, playing basketball and computer games. Most common activity he does if there are classes is walking. For about 45 minutes, he walks about 1 kilometer every afternoon/night to go home. He does this regularly unless raining or has some injuries. He does not complain any discomfort in it. He uses his spare time listening to radio, surfing the net and playing basketball. He loves to play basketball because he loves to sweat a lot and he enjoys playing this ballgame. He can manage to perform his tasks alone without the assistance of somebody

Sleep-rest Pattern: He commonly sleeps for about 5-6 hours a day. He has some problem with his sleep pattern. He has a hard time to put himself to sleep. His sleeping ritual includes reading books and listening to radio. He has some hard time waking up due to lack of sleep hours. He does not take naps in the afternoon. He often relaxes his mind and body by being idle, watching, surfing net and listening to soothing music so that he can sleep undisturbed.

Cognitive and Perception Pattern: He has no problems concerning with his visual and hearing. He doesn t have any difficulty with understanding with others. He easily remembers things by staring at it and analyzing it. He communicates through verbal and written. He doesn t have difficulty with decision making and tries to consider all possible outcomes and consequences when making decisions. Self-perception and Self- concept Pattern: He described himself as a happy-go-lucky guy. He recognized himself as someone who is hard to deal with. He has a positive outlook in life despite of troubles. He expresses himself in sports and in performing various tricks and performances. He enjoys the things he does especially learning. He has many achievements but he wants a low-profile about it. He does not tell it to anyone unless necessary. He is very aware and concern about the people around him but he tries to help them in a secret and mysterious manner. He is not that friendly at all. He usually gets mad whenever someone ignores him or disrespects his right and beliefs. Most people describe him as sensitive and moody; some says he is serious and mysterious. He considers sports, reading and sensitivity as his strengths and being moody, too much sensitivity and arts as his weakness. Role-relationship Pattern: He lives with his whole family. He belongs to a nuclear family. The problems are most of the time solved individually but if it involves the whole family, his father decides by seeking suggestions from the whole family members. His mother is the one who does the budgeting. His responsibility in their house is do the chores and to assist his father. He usually keeps his problems and never reveals it to his family but sometimes they can notice it. He is more comfortable alone but he can be sociable to few people only who can accept him. He is shy that is why he has hard times communicating to others. Though he is lonely, he still prefers to be alone. He only considers few friends that he can rely on. Sexuality-reproductive Pattern: He does not have any sexual experience yet. He does not have undergone testicular examination. He has no known sexual disorders. He has no known reproductive tract infection. He does not visit a doctor.

Coping Stress Tolerance Pattern: He is seldom seen tense. He does not take any medicine if he is stress or tense. He usually get stressed whenever there are many things to do and when he is under time pressure. He usually deal with it by prioritizing what should be done first and organizing what to be done. He usually solves his problems alone but may need suggestion to some people in aspects he does not know. He practices meditation every night to soothe his mind to be free from all disturbances that can stress him. He is moody most of the time that may affect his thinking process and decision-making skills. He cries whenever he has a hard time solving his problem but eventually laughs at himself when it is over. He accepts challenges as natural events in life. Values and beliefs pattern: The most important thing for him is his family and his true friends. He never gets what he wants easily but he achieves it by exerting effort and constant trying. He sees future as a wide world with limitless boundaries to unravel. He wants to learn many things in life and be the best man he can be. He is not religious man but he believes that God will help him reach his goals if he will do his best. He believes in God and he knows that God is the mighty force he can hold on in times of troubles. He views life as his own. He says that Life is yours alone. Live and rise to it. He believes that he is the captain of his life and the meaning of it is being the one who can complete its journey back and forth to the place he came from.

LEVEL OF DEVELOPMENT
PHYSICAL DEVELOPMENT Physical growth during adolescence is greatly influenced by a number of factors. Some of these are heredity, nutrition, medical care, illness, physical and emotional environment, family size and culture. In J.E.D s case heredity is one of the factor that affects his physical growth. At the age of 17 he already stands 5 8 much taller compared with the normal adolescent of his age. And because extremities grow before the trunk, he looks leggy, awkward and uncoordinated. His shoulder, chest and hips are in full size. At this age skull and facial bones also change. His forehead becomes more prominent and jawbones are developed. J.E.D is very conscious about his looks. He always wanted to look good and pleasant in the eyes of others .But because sebaceous glands are activated under the influence of androgens on this age he experience of having pimples and comedones (blackheads and whiteheads) on his face. To manage this he makes use of skin care products appropriately for his age. He was also able to develop secondary sexual characteristics like growth of pubic hairs on axilla and genital area. His voice also changes. He has now a bigger and deeper voice. He also has Adam s apple.

PSYCHOSOCIAL DEVELOPMENT According to Erikson s Psychosocial Theory adolescents are under identity vs role confusion. Adolescents seek answers to who am I? and what am I to be? The psychosocial task of the adolescent is to establish identity. On J.E.D s case little by little he establish his own identity/ He is very much concern about his bodies, appearance and physical abilities. Hair styling, skin care and clothes become very important for him. Right now he is still dependent to his parents but sooner he also wants to gain dependence and live life of his own.

PSYCHOSEXUAL DEVELOPMENT According to Freud s psychosexual Theory adolescents are under genital stage. He admits that his sexual desire is now the need to be with someone in a mutual way. He also had past relationships of his opposite sex.

COGNITIVE DEVELOPMENT Cognitive abilities mature during adolescence. According to Piaget adolescence is under formal operations stage of cognitive development. On J.E.D s case he can think beyond the present and beyond the world of reality. He is highly imaginative and idealistic. He tries to consider things that do not exist but that might be and consider ways things could be or ought to be. He is now more informed about the world and his environment. He uses new information to solve everyday problems and knows how to communicate with adults on most subjects. He usually selects his own area for learning. He explores interests from which he may evolve a career plan.

MORAL DEVELOPMENT According to Kohlberg, adolescents are usually at conventional level of moral development. On J.E.D s case he accepts Golden Rule and abides social order and existing laws. He tries to examine his values, standards and morals. He sometimes discards the values he had adopted from his parents in favor of values he considered more suitable.