Beruflich Dokumente
Kultur Dokumente
_______________
_______________
In Partial Fulfillment of
the Requirements for
the course Nursing Care Management 203
_______________
By:
June 2010
COLEGIO SAN AGUSTIN-BACOLOD
College of Nursing
PSYCHIATRIC NURSING CASE ANALYSIS RECORD (PNCAR)-INITIAL
Within 50 hours of duty in National Center for Mental Health, I will be able
to:
KNOWLEDGE:
1. Identify the predisposing and precipitating factors that contributed to the illness
of the client.
2. Explain the relationship of the client to her family and how it added to her
illness.
3. Retrieve important information such as client’s diagnosis, chief complaints,
etc., for the psychiatric case study.
4. Define terms used in the case study such as Bipolar Affective Disorder and
Schizophrenia.
5. Formulate a complete and detailed psychiatric case study using the data
gathered from the client’s chart and from the client herself.
SKILLS:
1. Produce a factual psychiatric case study by utilizing the data gathered during
chart-reading and interview of the client.
2. Create a comprehensive psychopathology in relation to the illness of the client.
3. Discuss client’s illness thoroughly and clearly.
4. Interpret the different conscious/unconscious movements or behaviours made
by the client.
5. Minimize the use of non-therapeutic techniques when communicating with the
client.
ATTITUDE:
1. Promote confidentiality while working the case study.
2. Relate ideas or terms that is vague to the clinical instructor and group mates.
3. Establish a professional working relationship with the client effectively.
4. Respect the client’s attitude and answer when communicating with her.
5. Encourage a positive outlook when doing the case study.
CASE ANALYSIS PROPER
I. ADMISSION INFORMATION
General Admission Information
Client’s initials___AP___ Age _13_ Gender _Female Marital status ____Single______
Name of significant other _Elena Pedrosa_______ Contact number _____N/A________
Residential address _Brgy. Tacuranga, Palo, Leyte_____________________________
Pavilion/Unit/Room number and name _Pavilion 10_____________________________
Date & time of admission _February 20, 2009 / 3:35 PM_________________________
Name of Attending Physician _Dr. MCA______________________________________
Conditions of Admission
Check one (1) only: Voluntary ( ) Involuntary ( )
Accompanied by (family, friend, police, other) _Elena Pedrosa-sister_ ______________
Route of admission (ambulatory, wheelchair, trolley) _ambulatory__________________
Admitted from (home, other facility, street, OPD section) _OPD section ___________
TP A
F A T Ac A E Patient La Lb E A