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Oniphas Homewoek - Copy

Jun 04, 2018



Nichola Tappin
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  • 8/13/2019 Oniphas Homewoek - Copy


    Name: Onipha Tappin

    Date: 24/11/13

    Teacher: Sis Zac-Gore

  • 8/13/2019 Oniphas Homewoek - Copy



  • 8/13/2019 Oniphas Homewoek - Copy


    Table of Contents


    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


    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

    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


    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




    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 to preventbehaviouraldisturbances.- educatesupportpersons ontheimportanceaiding the

    client to takemedications.this aids incomplianceand offerssupport

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  • 8/13/2019 Oniphas Homewoek - Copy