NR 509 Week 6 Shadow Health Mental Health Physical Assessment Assignment (GRADED).

Document Content and Description Below

Unformatted text preview: 6/6/2018 Mental Health | Completed | Shadow Health Mental Health Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Resu... lts Overview Lab Pass Subjective Data Collection: 43 of 44 (97.7%) Transcript Subjective Data Collection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Objective Data Collection Education & Empathy Indicates an item that you found. Indicates an item that is available to be found. Documentation Lifespan Category Scored Items Not Scored Review Questions Self-Reflection Patient Data Experts selected these topics as essential components of a strong, thorough interview with this patient. A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports difficulty sleeping and "feeling nervous" Reports seeking treatment because she has an upcoming exam and feels "too foggy to study" Reports excessive worry and "racing thoughts" before bed History of Present Illness Asked about onset and duration of symptoms Reports difficulty sleeping began 3 1/2 weeks ago Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks 1/7 6/6/2018 Mental Health | Completed | Shadow Health Asked about frequency of symptoms Reports difficulty sleeping at least four or five times a week Asked about aggravating factors Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about Denies naps during the day Reports drinking caffeine to stay alert Reports stopping caffeine use after 4 P.M. Denies alcohol use before bed Denies drug use before bed Reports respiratory problems are controlled and not interfering with sleep Asked about relieving factors Reports sleeping more easily if she can distract herself from her "racing thoughts" Reports no exercise Asked about impact of sleeping problems on daily living Reports feeling tired and "out of it" most of the time during the day due to lack of sleep Reports no increased chance of drifting off during the day despite lack of sleep Followed up about patient's experience feeling "out of it" Asked about anxiety symptoms Reports feeling slowed down and tired, having trouble focusing, and generally feeling "less sharp" Reports feelings of anxiety as "thoughts she can't turn off" and "being on edge" Reports worry about the future, but no sense of impending doom Reports no panic attacks Reports difficulty concentrating due to fatigue from lack of sleep Reports only restlessness occurs just before bed Reports slight irritability due to fatigue Asked about impact of anxiety on daily living Reports stress only interferes with daily life because it interrupts her sleep Reports stress does not prevent her from completing her usual activities Asked about sleep quality Reports falling asleep often takes more than an hour 2/7 6/6/2018 Mental Health | Completed | Shadow Health Reports waking up two or three times during the night for "at least ten minutes" Reports waking in the morning feeling "out of it" and not rested Asked about sleep habits Reports going to bed "around midnight," but feeling "too nervous" to sleep Reports actually falling asleep at 2 or 3 AM Reports reading before bed Reports no screen use (television or computer) before bed Reports average wake time of 8 AM Reports sleeping an average of 4 or 5 hours a night Reports sleeping alone in a quiet room Asked about stress causes Reports feeling stressed about studying and "the future" Reports CPA professional qualifying exam in one month Reports upcoming graduation from college and need to secure employment Asked about stress coping Reports coping with stress by going to church Reports coping with stress by "staying organized" Reports coping with stress by talking to friends and family Reports usual stress coping strategies are less effective Asked about stress quality Reports feeling nervous and worrying about the future, with racing thoughts Confirmed use of medications Confirms medications (no new medications reported) Medical History Followed up about sleep medication use Denies taking OTC sleep medications Denies taking prescription sleep medications Confirmed allergies Confirms allergies (no new allergies reported) 3/7 6/6/2018 Mental Health | Completed | Shadow Health Asked about history of sleep problems Reports usually falls asleep very easily and "sleeps like a log" Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own Psychological History Asked about history of psychiatric illness Denies history of depression Denies history of anxiety Denies current psychiatric illness Denies history of psychiatric illness Denies bipolar disorder Denies schizophrenia Denies obsessive compulsive disorder Denies past psychiatric treatment Denies past psychotropic medications Asked about symptoms to determine depression risk Reports belief she does not have depression symptoms Reports no difficulty making decisions Reports slightly decreased energy due to lack of sleep Denies feelings of guilt or worthlessness Denies feelings of hopelessness Denies loss of enjoyment in activities usually found enjoyable Reports slightly less appetite because she feels "a little queasy" from lack of sleep Denies feelings of sadness Asked about suicidal tendencies Denies suicidal thoughts Denies suicidal behaviors Denies past suicide attempts Asked about self-harm Denies history of self-harm Asked about past trauma Denies past trauma Asked about history of violent thoughts Denies angry outbursts Denies past violent behavior Denies desire to harm others 4/7 6/6/2018 Mental Health | Completed | Shadow Health Social History - Education and Work Asked about employment status Currently employed Works for a shipping company Works 32 hours a week Reports rarely missing work Asked about education and learning ability About to receive B.A. in Accounting Denies past special education courses Denies learning disabilities Denies speech problems Denies hearing problems Asked about hobbies Hobbies are reading and watching television Asked about legal history Denies past legal issues Asked about military service Denies military service Social History - Housing and Support Network Asked about living situation Lives in a house Lives at home with mother and sister Asked about family dynamics Has a brother and a sister Father died in a car accident almost two years ago Reports family is "tight knit" and gets along well Asked about support network Reports close group of friends from middle and high school as well as from church Spends time with friends "a few times a month," though less so with her recent schedule Asked about spirituality Identifies as Baptist Reports attending Baptist church regularly since childhood 5/7 6/6/2018 Mental Health | Completed | Shadow Health Social History - Substance Use Asked about substance use Reports past marijuana use Denies current substance use Followed up on past marijuana use Reports smoking marijuana for "five or six years" Reports last smoked marijuana when she was "20 or 21" years old Reports quitting marijuana because it "just wasn't fun anymore" and was bad for her asthma Reports marijuana use was for recreation, not to treat or mitigate specific symptoms Asked about alcohol use Confirms alcohol use Reports going out "a couple times a month" Reports having "a few drinks" when she goes out Reports 10-12 alcoholic drinks per month Reports drinking to "relax and blow off steam" Denies that anyone has asked her to stop drinking Denies guilt associated with drinking Asked about drinking and driving Asked about tobacco use Reports that she and her friends "usually take a cab" Denies history of tobacco use Denies current tobacco use Asked about prescription drug abuse Denies prescription drug abuse Social History - Relationship and Sexual History Asked about relationship status Currently single Asked about relationship history Reports past relationships Last relationship ended three years ago Most recent relationship lasted three years Reports she has never been married 6/7 6/6/2018 Mental Health | Completed | Shadow Health Asked about sexual history Reports past sexual relationships Reports three previous sexual partners Reports last sexual encounter was with boyfriend three years ago Asked about abuse history Denies history of abuse Denies past physical abuse Denies past verbal abuse Family History Asked about relevant family history Denies psychiatric illness in the family Reports uncle has a "problem with alcohol" Denies family history of drug addiction Denies family history of suicide Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 7/7 ... [Show More]

Last updated: 1 year ago

Preview 1 out of 7 pages