1803NRS Foundations Of Professional Nursing Practice


Socio demographics – summarise the demographic information for the person – age, sex, marital status, number of children, financial status, transportation, who they live with, employment etc.

Presenting issues and provision diagnosis – describe the problem or symptoms that the person presents with. Describe any physical, emotional, or sensory symptoms reported by the person. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that have been conducted should be noted. A provisional diagnosis is indicated by placing the specifier “provisional” in parentheses next to the name of the diagnosis. For example, it might say something like 309.81 Posttraumatic Stress Disorder (provisional). Once more information is gathered and a final diagnosis is made, this specifier is removed (see the course site for more information). Try to link the presenting issues for the person to your provisional diagnosis. Make sure to use the DSM-V for your diagnosis (see the course site for the link to online DSM-V)

Case: Janice

Janice is a 17 year old woman living in a remote Aboriginal community.  She is 20 weeks pregnant.  Her grandmother has brought her to the community health centre for a check up to make sure both she and the baby are okay as she has noticed that Janice has been acting a little strange lately.

Janice reported a prior history of petrol sniffing and drinking alcohol that started at 10 years of age.  Janice stated that she stopped using several years ago after experiencing hallucinations and paranoid thoughts. At this time, she was linked with an Indigenous youth mental health service but has not had any contact with mental health services for over 2 years and currently does not take any medication.  Janice reports that she sometimes hears voices from the spirit world but does not find these distressing. Janice reports that lately she has been having difficulty sleeping and is feeling ‘moody and angry most of the time’.
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