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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