Psychiatric Nursing Care Plan
Student Name:| Duaa Elkhatib| | Date:| 8/10/2010|
Date of Admission:| 3/10/2010| | Ward:| Female Admission| Psychiatric Diagnosis:| Schizophrenia| | Pt. Initials:| S. S. S.| | | | Chart No.:| 7/067|
Instructor: HANA JADDOU
Nursing Process Application
1. Identification Data:
Age: 41 years old| Sex: Female| Residence:| Al-Haooz, Al-Khalil| | | Religion:| Muslim|
| | Occupation:| Unemployed|
Marital Status:| Divorced| Informant:| Middle brother|
2. Socioeconomic status & living arrangement:
The patient’s family is considered to be low-middle class. She lives in her parents’ house in Hebron. Her father, mother, youngest brother, and one sister live with her. Other than these siblings, she has four other brothers and one sister who are all married with families. She is divorced with no children.
3. Past medical history:
The patient got pregnant once and had a Normal Vaginal Delivery. There were no complications during or after birth for the mother nor the child. The child died suddenly with no apparent cause four months later. Two years ago she had a complicated case of appendectomy.
4. Past psychiatric history & previous psychiatric admissions: The onset of the patient’s disorder occurred after the sudden death of her four month old daughter. She became depressed afterwards and then began treatment. After two years of her daughter’s death, her husband divorced her. This worsened her state of mind. Her first admission to the hospital was 1/11/2010. The main reason for her admission was because of her depressive state, continuous crying, and outrageous yelling. She then caused problems and claimed that her family is trying to kill her, so she ran away from the house. She has been admitted two times before in the past two years due to her not taking her medical treatment properly, which lead to a relapse of her previous behaviors and attitudes of delusions and aggressiveness. She has had many trial leaves within these admissions. 5. History of present illness:
a. Chief complaint:
The chief complaint is related to the fixed beliefs of the patient, claiming that her family wanted to kill her so she ran away. She says that the people living with her are monsters and her parents are dead. The monsters are here to take their place. She gets aggressive and hits her mother. b. Reason for admission:
Ever since the sudden death of her infant daughter, she has been very depressed. She continuously cried for months and shouted all the time. She has fixed beliefs of her family wanting to kill her so she ran away. She does not believe the people living with her are her real family, but monsters taking their place because her real family died. She says they brought her to the hospital for revenge, even though she didn’t do anything to them. She has bizarre delusions and she hits her parents. She also insults them orally and disturbs the neighbors. Her brother brought her to the hospital because she could not be controlled. She also tried to kill herself, because she thinks her family is going to kill her.
6. Personal history:
According to the patient’s family, reliable resources, her whole life she was normal like all the other girls. At the age of 18 she was in her last year of school, literature section, but failed the national exams. She then got married afterwards. She gave natural birth to a baby girl who died suddenly four months later. After two years of being in a depressive state from the death of her daughter, her husband divorced her due to her mental state (he has now been dead for five years). After one year she underwent appendectomy; it was a complicated case. She does not work but her hobbies include sewing and drawing. When she stops following her treatment, she relapses and gets aggressive. Her bizarre delusions are usually around the same subject but have minor differences. They are auditory...