Alcoholism
Essay by review • April 25, 2011 • Research Paper • 2,325 Words (10 Pages) • 1,240 Views
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 family members
Withdrawal
"cold" treatment
Indifference
6. Interaction Pattern
6.1 Do you voice your thoughts and feelings to your family?
NO.
6.2 Client's feelings when he interacts with family and friends.
Masaya. Tahimik.
7. Spiritual Patterns
7.1 Client's concept of God.
The client sees God as an all powerful being able to bring boon and/or bane to people whenever people deserves it.
7.2 Significance of specific religious rituals or practice to client.
No specific religious rituals were noted/ observed by the client. The client though wears a rosary on his right wrist that he continually touches.
III- DEVELOPMENT HISTORY
(Based on Erikson's psychosocial model and Freud's psychosexual stages)
Trust vs. Mistrust: sensory- oral (0-18mos)
Unremarkable. First of 2 siblings.
Client is able to relate with others, share and has optimism and hope in life.
Autonomy vs. Shame and Doubt: muscular/ anal (18mos- 3 years)
Unremarkable.
Client exhibits good self-esteem, confidence and cooperativeness.
The client also exhibited poor self control and delaying
...
...