Psychiatric nursing case history example

Ask the patient about doing things without thinking or planning. If the patient is a child or adolescent, asking what grade the patient is in also may be appropriate. Without a specific format, important information may be missed. For example, an apple and an orange good response is "fruit"; poor response is "round"a fly and a tree good response is "alive"; poor response is "nothing"or a train and a car good response is "modes of transportation".

History and Mental Status Examination

Obtain as much detailed information as possible. If possible, record the medications and dosages family members took for their illnesses. Also ask if the patient has a family, and, if so, if the patient maintains contact with them. If possible, have the patient bring his or her medications to the visit.

At least ask a few screening questions regarding medical illnesses such as do you see a doctor regularly. The time it takes to complete the initial interview may vary; however, with experience, interviewers develop their own comfortable pace and should not feel rushed to complete the interview in any time that is less than comfortable for either the interviewer or the patient.

Patient was labile, but appropriate. The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself.

If the patient is not employed, inquire about whether the patient currently is looking for work. Past history of intent in Februarybut no past history of attempts, or self-mutilation.

Ask the following types of questions to help determine homicidal ideation or intent. Examples may include that the patient agreed to voluntary acceptance of treatment, has strong verbal skills, or exhibits above average intelligence, just to name a few.

These first few observations can provide important information about the patient that may not otherwise be revealed through interviewing or one-on-one conversation.

Be sure to ask patients if they have any questions regarding their treatment plans. Patient states that her husband has been supportive throughout her psychiatric stays.

Trends in suicide rates among persons ages 10 years and older, by sex, United States, For example: submit information on an alcohol blood level procedure that was performed on an alcoholic patient.

Indicate any abnormal levels and its significance. Pyschiatric Nursing Case History with Diagnosis, HPI, ad Diagnostics 1.

Identifying Statement 59 year old, married white female who was brought to the Emergency Department by the police by herself because of public intoxication with suicidal ideations. SAMPLE HISTORY and PHYSICAL Current physician: Sees Dr. R. McDonald for psychiatric meds PCP is Ob/gyn physician, Dr.

Psychiatric Nursing Case History Example

Sam Curry in Texas City‐ last visit was in 11/04 Past Psychiatric History Patient first saw a counselor at age 15 for 6 months, with some relief of symptoms. Nursing Health History Nursing health history is the first part and one of the mostsignificant aspects in case studies.

It is a systematic collection ofsubjective and objective data, ordering and a step-by-step processinculcating detailed information in determining client’s. An Example Psychological Case Formulation: PTSD Treatment Using CBT [C] Resident's Guide to Clinical Psychiatry.

HISTORY TAKING PSYCHIATRY (SAMPLE) My patient ali raza, 17 years of age, male, married for last 1 month having PAST PSYCHIATRIC HISTORY: & previous treatments My patient also attempted deliberate suicide attempt to 5/5(1). Examination of Three Case Studies of Caring for Psychiatric Patients on a Medical Surgical Unit.

Psychiatric nursing case history example
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