Faculty of Health Sciences

Department of nursing
Tripoli Campus

Psychiatric and mental health

NURS 419

Case Report #2

Prepared By: Razan Nasereddine

ID:201803107
Dr’s Name : Maha Dankar

Date: 2/12/2019
Outline:

1. Patient initial and habits.

2. Cause of admission/history of present illness.
3. Past medical and surgical history and blood tests
4. Symptoms reported by the patient.
5. Medical and nursing management provided to the patient.

1.A) Patient initial :

 Patient’s name : Moufida Al Sayed

 Age : 23 years old
 Date of birth: 5/3/1996
 Marital status : single
 Living : lives with her father and her step mother and kids
 Address : Tripoli
 Occupation : worked a little bit in her father’s place as a cashier
 Education : brevet
 Patient has two sisters and two brothers from another mother
 Patient’s dad visits her every week

B) Patient habits:

 Sleeps well (eight hours/day)

 Eats well ( three meals/day)
 Doesn’t drink alcohol nor smoke
 Takes shower every 2/3 days
 Listen to music
 watch TV
 sometimes do activity
2. Cause of admission:

 Patient admitted to Rached Soukari Hospital in 2/10/2018 through the admission door
under the psychologist doctors name: Dr Jamal Hafez , Dr Rached Soukari and
medical doctor : Dr Georger Safourin
 Admitting diagnosis: depression and trouble in character
 Chief complaint: fungus pathology and depression
 Medical observation on entry : hallucination and polymorphic delirium

History of present illness:

 Family conflict and compartmental problem

 Past psychiatric history: compartmental problem
 Social history : living condition, depression and no employment with positive
relationship

3. past medical history:

 Patient has previous hospitalization in Dar AL Salib Hospital where her father took
her and she stayed for 2 months
 Patient’s all body systems are normal
 Patient accept transfusion
 Social, character, and facial problems and family divorce
 No developmental and medical history
 patient when entered the hospital her vital signs: blood pressure was 12/70mmhg ,
pulse 80 beats/min, temperature 37 degrees
 Patient GAF was 71 at admission.

 patient evaluation on scale DSM-IV-TR showed:

i. axis 1: major depression and fugue
ii. axis 2: absence of diagnosis
iii. axis 3 : absence of diagnosis
 iv. axis 4: stress, family problem
v. axis 5: GAF 71

71 – 80 If symptoms are present, they are transient and expectable reactions to

psychosocial stressors (e.g., difficulty concentrating after family argument); no more than
slight impairment in social, occupational, or school functioning (e.g., temporarily falling
behind in schoolwork).

Patient surgical history:

Patient had an eye operation (cataract)

4. Symptoms reported by the patient: (2/10/2019)

 sudden left of house

 incapacity to remember her past
 symptoms of toxic mania: patient doesn’t use any substance
 personality and characteristics: hesitant and timid
Incapacity to recognise
Incapable to explain
 attitude during assessment: naïve and masked

 Semiology psychiatric: (15/11/2018)

 Appearance : little bit over weight

Dress neatness: proper hygiene

Clothes: nice and clean

Posture: nice
 Visual contact: normal

 Motor activity: normal

Movement: normal

Walk: normal

 Language : little loquacious

Vocab: poor

Volume: low

Communication: patient communicates well

 Emotional: depressed

Observation:

 Depressive humor
 Bradykinesia
 Fugue multiple times
 Disorientation(temporal and partial)
 Lack of judgement
 Patient doesn’t have logic thinking

5. Medical and nursing management provided to the patient:

Medical management:

Take medications as ordered from the physician.

Patient medications (1/10/2019):

 Prometal 25mg /day

 cybalta 60mg (0.5 at night)
 resperdal 2mg(1 at night)
 toramat 50 mg (1 at the morning and 1 at night)
Conclusion: moufida suffer from fugue dissociation present the following symptoms
sudden left from house and incapacity of remembering past

After eliminating a recurrent depression and maniac episode and mixed depression and
no any perturbation due to substance abuse and general medical affection

Nursing management:

Interventions for coping and treating depression:

 Discuss the overall treatment plan with the patient and the person who will support
him.
 Assume active role in initiating communication. This can be done by sharing
observation of patient’s behavior, speaking slowly and allowing ample time for him
to respond, encouraging him to talk and write down feelings, and by providing a
structured routine which may include non-competitive activities.
 Educate patient about depression. Explain that depression can be eased by expressing
feelings and engaging in pleasurable activities. Emphasize that there are effective
methods available for relief of symptoms.
 Help patient recognize distorted perceptions and link them to his depression.
 Ask patient whether he thinks about death or suicide. Signal an immediate need for
consultation and assessment. Risk of suicide is higher with lifting of depressed mood.
 Stress the need for medication compliance. Review adverse effects with the patient.

Interventions for helping the patient have logic thinking:

 Talk to the patient about the whole problem and let him talk all what he think and feel
 Let the patient set solutions for his problem
 Educate the patient about life priorities and its importance about setting priorities in
life
 Talk to the patient every day to see what he thinks today and if any changes occurred
 Talk with the patient about the importance of listening to parent’s advice and never
disobeying them
 Talk about the side effects when the parents mistrust their kid and start to doubt him
 Let the patient set life goals and help him achieve them
 Try to distract the patient about bad thoughts that he used to like
 Discuss with the patient about the positive feedback when there is trust between
patient and family