Oniphas Homewoek - Copy

8/13/2019 Oniphas Homewoek - Copy

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Name: Onipha Tappin

Date: 24/11/13

Teacher: Sis Zac-Gore


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Introduction


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Table of Contents

Introduction

Biographical Data

Chief Complaint

Current history.

Past Medical and Surgical History

Current Health Status..

Family History..

Psychosocial History.


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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


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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 H istory

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


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Family H istory

Mother has diabetes mellitus

Psychosocial H istory

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.


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Head-to-Toe Assessment

Height: 163cm (54) Weight: 160lbs

B/P: 120/78 Temp: 98.4F

Pulse: 78 bpm 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.


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Nursing Diagnosis

Non-compliance with medication regimen related to behavioural changes evidenced by patients

mother verbalizing complaints with patients behaviour.

Care Plan

Assessment NursingDiagnosis

goal Interventions OutcomeCriteria

Young womanadmitted dueto reports of

disturbedbehaviouralchanges, she

is non-compliant

withmedicationregimen.

Non-compliancewith

medicationregimen

related tobehavioural

changesevidenced by

patient beingrestless andcombative.

Patient willceasesmoking with

adequateteaching andcounselling

-ask thepatient whatis her reasonfor notcomplyingwith themedicationregimen. toknow herspecificreasons fornot takingthemedications.-educatepatient ontheimportanceof takingmedications.To aid incompliance.-providemeasures toaid patientwith copingwith the sideeffects ofmedications.To better aid

Patient hasceasedsmoking withteaching andcounselling


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compliance-ensure thepatientreceivesprescribed

medicationsas ordered.to. to preventbehaviouraldisturbances.- educatesupportpersons ontheimportanceaiding the

client to takemedications.this aids incomplianceand offerssupport


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