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NURSING ASSESSMENT
A. Biographic Data
NAME: AGE: GENDER: ADDRESS: DATE OF BIRTH: PLACE OF BIRTH: NATIONALITY: CIVIL STATUS: RELIGION: HIGHEST EDUCATIONAL ATTAINMENT: DIAGNOSIS: DATE ADMITTED: TIME ADMITTED: TYPE OF ADMISSION: Mr. AG 27 y/o Male Orion, Bataan August 8, 1985 Orion, Bataan Filipino Single Iglesia Ng diyos kay Cristo Hesus Sunga ng Haligi at Katotohanan Vocational Graduate Bipolar Manic Disorder September 20, 2012 10:00AM Old (4x)
CHIEF COMPLAINT: Impaired sleep Aggressive He is punching the house maids He kicked his 12 year old niece Harmful to brother and father Patronizing smile - Source: Mr. AG (brother)
During Institutionalization
When the client first admission to the hospital he refused to enter the facility, claimed that his fine, evasive with sharp stare and has a direct glances on the Doctor, he also projected disturbances, has poor insight and judgement and he denied perceptual disturbances. After he took his medication he was able to watch television but he complaints headache. The patient was also placed on a safe keep for two days due to his discipline behaviour and after two days he was placed to the male ward. His taking medications that will help him to improve his condition like Risperidone, Chlopromapine, Diphenhyrmine, Clozapine, Clonazepam, Lithium carbonate. According to the nurse in charge, our client is quite and manageable. He can also follow instructions and whenever he asked what his wish is, he will always answer to go home and see his family.
Upon Handling
On the first day of Nurse Patient Interaction our clients has an inappropriate affect, he doesnt smile often times, he doesnt open up things about his personal life, We also noticed that he has tremors on his hand but as the Nurse Patient Interaction goes by, our client showed appropriate affect, his mood is appropriate to the situation, his tremors lessen, he actively participated on our activity. Ag is cooperative and he can groomed himself independently, he can answer question appropriately but during our Interaction he manifested defense mechanism like Denial and suppression, he denied the death of his mother because he doesnt want to remember that, because he stated that
ear and music that keeps on playing on his mind. When he was admitted to MMH last April 3, 2012 he denied that he was accusing his sister-in-law about such thing, he also said to the doctor that his fine and there is no problem with him, He denied all the things that happened. On his fourth admission it has the same complaints, he was doing the same thing repeatedly. Our client is a Non-smoker.
her mother is his stressor. He also add that he wanted to go home to see his family.
C. Previous Illnesses
According to the client he doesnt have any major illness before he was admitted to the institution. We also review his chart and there were no findings of any kind of disease on his history.
E. Family History
According to the client, he has a good relationship to his family especially to his mother who died with breast cancer. Our client is family oriented because he always wanted to spend his special day like birthday and Christmas with his family in Orion, Bataan. He added that his grandfather on his maternal side died with pneumonia and has an asthma, he stated that he was closed to his Lolo.