Topics: Schizophrenia, Self-esteem, Delusional disorder Pages: 17 (5705 words) Published: April 23, 2013
Page| Subject|
3| Identification data |
3| Socioeconomic status and living arrangement|
3| Current problems and chief complaint |
4| History of the psychiatric illness and admission|
4,5| Personal history |
5| Family history|
6| Medical History |
6-8| Life value|
9| Social habits and living patterns|
9| General appearance and physical characteristics|
9| Speech |
9| Psychomotor activity|
9| Anxiety level and its effect on client|
11| Mental status Examination|
12| Present treatment |
12| Other examinations|
12| Attitude toward interviewer|
13| Psychiatric Diagnosis: DMS IV|
14| Problems and nursing diagnosis|
15| Nursing care plan|
22| References|

Week of experience: 9th wk students: Maisa, Sama& Fida Date of admission: 7\10\2011 Initials: A.G.S Psychiatric Dx: Schizo Affective disorder ward: rehabilitation Instructors name: Mrs. Nadia Sbeeh & Mr Abdallh Al wawy

1- Identification:
Age: 46 yrs old Sex: female Residence: Dr. Ivonah Education: 11th grade religion: Christian Marital status: single 2- Socioeconomic status and living arrangements:

A.G.S is a 46yr old single female she used to live with her parents and one sister in Bethlehem, at a building in the second floor; their house consists of 3 rooms, one living room, one gust’s room, a kitchen and a bathroom. The air in the area is unclean as she mentioned. There are permanent electricity, water and sanitation services, not far away from the main road; stairs within the building are with balustrades. The general economic status is good her father is a carpenter and her mother was a translator, she had several jobs but all was temporal, now adays she has no job her father is the one who pays for all her expenses. Her family has good relationships with relatives and neighbors, all her life she had few friends and now she doesn’t see them a lot. She used to be close and has a good relationship with her mom who died one year ago after an MI at the age 67yrs. When she goes out the hospital for a holiday she stays at her sister’s home in Bethany. 3- Current problem and chief complaint:

She was admitted to the hospital on 28\8\2010. This was her first admission to this hospital, she complained of disturbed behavior manifested as unexplained laughing and crying, flight of ideas, loss of association, persecutory and reference delusions, suspiciousness, high level of guilt feeling auditory hallucinations and low self esteem. This relapse was happened after the death of her mom with an MI, she had guilt feelings because she thought that she died while she was angry with her. So after all these symptoms her father brought her to the hospital and she was diagnosed with Schizophrenia. Her treatment was only by medications, the symptoms she had is slightly decreased but never gone at all.

4- History of psychiatric illnesses and admissions:
* In her childhood between the age 8-10 yrs old she used to have convulsions every 6 months, with unknown reasons. * At the age 18 yrs, in the 12th grade her first lover guy left her to got marry with another girl after a while she fall in love with another guy also he left her ”she believes and trusts any stranger very fast and can easily follow him”, the first symptoms she experienced was laughing and crying with no reason, getting out the house so her mother took her to a psychiatrist called Basam al Ashhab. * After 10 yrs her sister died and she had a relapse so her family took her to Jordan to be seen by Dr Walleed Sarhan in ALrasheed Hospital she stayed there for about 3 months, she was diagnosed...
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