Scribd
Upload
362 views5 pages

History taking - 1

Uploaded by

ohc.topaz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
362 views5 pages

History taking - 1

Uploaded by

ohc.topaz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 5

History

Collection - 1

Submitted To,
Dr. Donit John
Vice Principal
Aurangabad College Of Nursing, Aurangabad.

Submitted By,
Mr. Amol B. Rathod
Final Year Msc Nursing,
Aurangabad College Of Nursing, Aurangabad.
MENTAL HEALTH & PSYCHIATRIC NURSING
PSYCHIATRIC NURSING HISTORY COLLECTION FORMAT
I) Demographic data:
- Name : - Ms. Akansha Hembrom
- Age : 24 yrs
- Sex : Female
- Marital Status : Single
- Religion : Hindu
- Occupation : Student
- Socio-economic status :
- Address : Bhim Nagar , room no 201 , Ch. Sambhajinagar
- Informant : Mother & father
- Information (Relevant or not) adequate or not : Adequate

II. Chief Complaints/presenting complaints (list with duration)


- In patient’s own words and in informants own words.
Sleeplessness x 3 weeks
- Excessive talking
- Over thinking
- Over possessive
- Day dreaming
- Big talk
- grandiosity
- Loss of appetite & hearing voices x2 weeks
- talking to self

III. Present psychiatric history /nature of the current episode


- Onset – 2 days before
- Sub acute – 7 days
- Gradul -
- Duration – 2 years
- Course – continuous
- Intensity - sometimes increasing or decreasing
- Precipitating factors – no
- History of current episode – patient feels that someone talking against
her , feels that something is harm her , day dreaming , big talk
- Associated disturbances – includes present medical problems
Disturbance in sleep, appetite, IPR & social functioning, occupation.
IV. Past Psychiatric history:
- Number of episode with onset and course – 2 days
- Complete or incomplete remission – incomplete remission
- Duration of each episode – 2 weeks
- Treatment details and its side effects if any – no any side effects
- Treatment outcomes – behaviourally improving
- Details if any precipitating factors if present – no any
V. a) Past Medical History
- No any past medical history
b) Past Surgical History
- No any past surgical history
c) Obstetrical History (Female)
- No any

VI. Family History:


- Family genogram –
- a family history include the particular generation
VII. Personal History:
- Pre-natal history - Maternal infections
- Exposure to radiation
- Check ups : patient is on irregular treatment
- Any complications :- No any
- Natal history - Type of delivery : - FTND
- Any complications
- Breath and cried at birth : - yes
- Neonatal infections
- Mile stones: Normal or delayed

Behavior during childhood


- Excessive temper tantrums
- Feeding habit
- Neurotic symptoms

Illness during childhood


- Look specifically for CNS infections
- Epilepsy

Schooling
- Age of going to School : - 6 yrs
- Performance in the School : - moderate
- Relationship with peers :- Good
- Relationship with teachers : - sometimes aggressive
- Look for conduct disorders

Occupational history
- Age of joining job :- She is Student
- Relationship with superiors, subordinates & colleagues : No
- Any changes in the job – if any give details - No
- Reasons for changing jobs – No
- Frequent absenteeism -
Sexual history
- Age of attaining puberty –
age of Menarche is 12 years

1. Pre morbid personality :


Personality of a patient consists of thosehabitual attitudes and
patterns of behavior which characterize an individual. Personality
sometimes changes after the onset of an illness. Get a description
ofthe personality before the onset of the illness.

2. Attitude to others in social, family and sexual relationship:


Ability to trust other, make and sustain relationship, anxious or
secure, leader or follower, participation, responsibility, capacity to
make decision, dominant or submissive, friendly or emotionally cold

3. Attitudes to self:
Egocentric, selfish, indulgent, dramatizing, critical, depreciatory, over
concerned, self conscious, satisfaction or dissatisfaction with work.
Attitudes towards health and bodily functions. Attitudes to past
achievements and failure, and to the future.

4. Moral and religious attitudes and standards:


Evidence of rigidity or compliance, permissiveness or over
conscientiousness, conformity, or rebellion. Enquire
specifically about religious beliefs. Excessive religiosity

5. Mood:
stability of mood, mood swings, whether anxious, irritable,
worrying or tense. Whether lively or gloomy. Ability to
express and control feelings of anger, anxiety, or depression.

6. Leisure activities and hobbies: Interest in reading, play,


music, movies etc. Enquire about creative ability.

7. Fantasy life: Enquire about content of day dreams


and dreams. Amount of time spent in day dreaming.

8. Reaction pattern to stress: Ability to tolerate


frustrations, losses, disappointments, and
circumstances arousing anger, anxiety or depression.
Evidence for the excessive use of particular defense
mechanisms such as denial, rationalization, projection.

9. Habits: Eating, sleeping and excretory functions.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy