NURSING HISTORY AND ASSESSMENT TOOL

An-Najah National University

Faculty of Medicine and health sciences
Mental Health and Psychiatric Nursing/clinical

Clinical case

Prepared by: Munther Abu Baker

Clinical instructor: Ahmad Amru

2013 - 2014

Please complete what considered being applicable for your clients

case

Client name: K.S

allergies

Allergies: No

Room number: In client

diet

Diet: Reguler

Doctor: Dr.Shaheen
Height/weight: --Age: 73yrs
TPR/BP : 37c - 140/80

Vital signs:

Sex: Female

Name and phone noof significant other: her neighbor A.K.

Race: Asian

Dominant language: Arabic

City of residence:Tulkarm city

Marital status: Widow

Diagnosis (admittingand current): Depression

Chief complaint:Organically the client is free from disease. He also
suffersfrom psychological problems including: sleepless,irretable,
anxiety, Depressed and isolation. Client sad that the cause of
admition that her brother sons was hate the client after her husband
died.

II. Conditions of Admission

Date: 30/10/2011

Time:Afternoon.

Accompanied by: Her neighbor.

Route of admission (wheelchair; ambulatory; cart) : wheelchair

Admitted from: Came directly from (Dair Al Um Treza) clinic.

III. Predisposing Factors

A. Genetic Influences
1. FAMILY CONFIGURATION:

Family of origin: Haifa city

Present family: Tulkarm city(alone).

Family dynamics (describe significant relationships between family

members):
Appears from the speech of the client that the relationship between the client and her family
member presence of problems between others, hate the client and take her alone
always with no any support.

2. MEDICAL/PSYCHIATRIC HISTORY:

a. Client: the client has D.M.

b. Family members: Not found

3. Other genetic influences affecting present adaptation. This might include effects
specific to gender, race, appearance, such as genetic physical defects, or any other
factor related to genetics that is affecting the clients adaptation that has not been
mentioned elsewhere in this assessment.
There is No serious psychiatric illness or genetic influences in the relatives of the client in the
family.

B. Past Experiences
1. CULTURAL AND SOCIAL HISTORY:

a. Environmental factors (family living arrangements, type of neighborhood,

special working conditions):The client before attending to the clinic was living in her home with her family,
neighborhood respected her and her family hate her. She was not work anything.

b. Health beliefs and practices (personal responsibility for health; special selfcare practices):---3

It seems that the client independent self-care in the most of her life activities Like going to
the toilet or bathing.

c. Religious beliefs and practices:Client embraces the Islamic religion and prayer, praise and always seems close to God.

d. Educational background:------ The client doesnt has any education level

e. Significant losses/changes (include dates):

The client losses her husband before couple of yrs.
f. Peer/friendship relationships: ---- The client has more friends before her relapses.
g. Occupational history: Not found

h. Previous pattern of coping with stress:

The client was when she has a stress go to her room and clean it.

i. Other lifestyle factors contributing to present adaptation:

Client has the previous technique of coping .

C. Existing Conditions

1. STAGE OF DEVELOPMENT (ERIKSON):

a. Theoretically: 19 adults need to form loving relationships and meaningful attachments

to others. Success at this stage leads to feelings of Love and Intimacy, while failure results in
isolation.

b. Behaviorally: The client feel self-respected and self-satisfaction within her life and she
seems a lovely adult; in addition the client has some problems in the time when she can't
control himself in being alone.

c. Rationale: The client seems normal in terms of theory, but she thinks about sudden
certain ideas effect on her mood in the term of behavior, so become isolated.

2. SUPPORT SYSTEMS: the client family especially brother sons doesnt always
provide psychological support for her (rarely).

3. ECONOMIC /SECURITY: Doesnt has an income, and there is no security.

4. AVENUES OF PRODUCTIVITY/CONTRIBUTION:

a. Current job status: No any job .

b. Role contributions and responsibility for others: responsibility toward herself.

4

5. Precipitating Event

A - Describe the situation or events that precipitated this

illness/hospitalization:

Suddenly before 2 month ago Client was slipped on the ground and
broken her pelvic bone, she complain from pain in her pelvic. Client
irregular in medication, flight of ideas, agitation,sadness mood,
sleepless, irritable and sometimes aggressive behavior.

Clients Perception of the Stressor

Clients or family members understanding or description of stressor/illness
and expectations of hospitalization:
Her family member didnt care.

6. Adaptation Responses

A. Psychosocial:
1. ANXIETY LEVEL (check and discuss the behaviors thatapply):
Client in interview look mild , Calm , Friendly, full alert and Cooperative; because this behavior
presence on client during interview.
2. MOOD/AFFECT discusses the most applied mood:
Client in interview looks Sadness.
3. EGO DEFENSE MECHANISMS write just what applied to the assigned
client (describe how used by client):
The client has the following:
Denial: the client say to me I dont have any disease "
Isolation :she spend most the time in her room far away of people.

low moderate high Things client likes about self:

5

She like that everyone loves her.

Things client would like to change about self:

She want to leave the hospital and start a new life full of love to others, or the god take her
life.

Objective assessment of self-esteem: The client respected her own self.

Eye contact: she keeps eye contact during the interview.

General appearance:
she is good self care with good address, bathing once/ week and not obese.
Personal hygiene:
The client dependence and cant bathe by himself, but she is need motivation .

Participation in group activities and interactions with others:

She is not participating with her friends in the activity of her department like preparing
the tables for lunch or washes the dishes.

5. STAGE AND MANIFESTATIONS OF GRIEF (discuss the applied behavior

only):
Client was having depression stage.

Describe the clients behaviors that are associated with this stage of
grieving in response to loss or change:

The patient suffers from the problems of stress, sadness and anxiety over what happened to
her, she sad for being away of her relatives.

6. THOUGHT PROCESSES (discuss the applied behavior only):

Client was clear and slow in thought association. The client Speak concept words and
logical speech and she answered the questions accurately and realistically without any
problems, also the client memory is good and she remembers a new and past events.

7. COMMUNICATION PATTERNS (discuss as many as apply):

The way to communicate with the patient indicates that his easy-versed from her word sand
her thoughts coherent, clear, and thinking about the question before giving the answer,
also she warned in the selection of her words and there is some of hesitate in speech.

8. INTERACTION PATTERNS (describe clients pattern of

interpersonal)

interactions with staff and peers on the unit, e.g., manipulative, withdrawn,
isolated, verbally or physically hostile, argumentative, passive, assertive,
aggressive, passive-aggressive, other):
As I see in the days watching the client and as the staff told me the client is cooperative not
aggressive in this time on clinic, passive but she demand something some times as : change
medication to another one.

9. REALITY ORIENTATION (check those that apply):

Oriented to:
Time :Yes

Person :Yes

Place Situation :Yes

10. IDEAS OF DESTRUCTION TO SELF/OTHERS?

If yes, consider plan; available means

Yes

No

B. Physiological

1. PSYCHOSOMATIC MANIFESTATIONS (describe any somatic)

complaints that may be stress-related): NO.

2. DRUG HISTORY AND ASSESSMENT:

Use of prescribed drugs:

VII. Summary of Initial Psychosocial/Physical Assessment:

Knowledge deficits identified:

Summery
K.S 73 years old female client complain of depression, admitted to the clinic in
30/10/2011 by her neighbor because of a fight between the client and brother sons.
The client was admitted to the another clinic before this time. The status of client
worse many times such as: anxiety, irritable ,flight of ideas, and depressed.
The client has brother sons and they hate her. There is no disease presented in the
family .
The client complains of pelvic pain and need for assistant.