Psychiatric Nursing History

PSYCHIATRIC NURSING HISTORY

I- GENERAL DATA

A. Personal Data

Name: Mr. A.E.G. Age: 25 Sex: Male

Civil Status: Single Religion: Roman Catholic

Address: 140 Molave St., Kayquit, Indang, Cavite.

Birthplace: V. Luna Hospital, Quezon City

Birthdate: October 5, 1981 Occupation: None

B. Source of Information

(x) patient (x) medical record

( ) relative, specify________________ ( )referral letter

( ) friend/s ( ) others

C. Chief Complaints

"gala ng gala"

"may bumubulong"

"salita ng salita", as verbalized by the mother

D. Condition on Admission

Date of admission: July 5, 2005

July 12, 2005

July 18, 2005

September 26, 2005

October 20, 2006

November 6, 2006

Accompanied by: Lorna Erni Gablan (mother)

Admitted for: Mental and behavior disorder due to alcohol

General Condition Upon Admission:

the patient assumes slouched posture, wide-eyed, cleans right ear with fingers, cooperative, without violent behaviors noted, without other signs of anxiety, constricted affect not congruent with mood, clear normal spontaneous and continuous speech, without delusions compulsions and obsession, intact memory.

II- SOCIAL FUNCTIONING

1. Family Constellation

2. Living Arrangements

The patient lives with her mother in a rented house in Cavite.

3. Occupation and Educational Status

High School Graduate

Claims to have taken units in both B.S. HRM and B.S. Agriculture but due to financial difficulties, he wasn't able to pursue his studies.

Former collector for a lending company

Former handicraftsmen

4. Recreational Activities

Hobbies

Singing, videoke, playing billiards, playing computer games, hanging out with friends, drinking sessions

Interests

Handicrafts, cooking, seamanship training, games

5. Coping Patterns

5.1 Individual Coping Pattern

5.1.1 People significant to client

Mother

Sister

Peers

5.1.2 People client talks with regular basis

Mother

Peers

5.1.3 Things client does to handle stressful situations in life

Drink alcohol

Withdrawal from social interaction

Denial

Projection

Rationalization

5.2 Family coping pattern

5.2.1 Manner of handling stress

Denial

Withdrawal

Rationalization

5.2.2 Manner of decision making

Matriarchal

5.2.3 Reactions to disagreement among