Focused Exam: Alcohol Use Disorder Results | Turned In
Mental Health Concepts in Nursing - January 2020, nur3525-ku_wpb_nur3525d1101132020
Return to Assignment (/assignments/303928/)
Your Results
Lab Pass
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Focused Exam: Alcohol Use Disorder Results | Turned In
Mental Health Concepts in Nursing - January 2020, nur3525-ku_wpb_nur3525d1101132020
Return to Assignment (/assignments/303928/)
Your Results
Lab Pass (/assignment_attempts/6214950/lab_pass.p
Overview Transcript
Subjective Data Collection: 51 of 51 (100.0%)
Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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SBAR
Reflections
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yiel better patient data. The following details are facts of patient's case.
Chief Complaint
Established chief complaint and reason for admittance
Reports car accident Reports injury
Reports passive suicidal ideation
History of Present Illness
Followed up on details of car accident Reports loss of consciousness
Reports being unsure of how the accident happened
Reports wearing seatbelt
Reports being the driver - no other passengers in car
Reports was told she would get a ticket for DUI
Followed up on alcohol use just prior to car accident
Reports drinking before accident
Reports being unsure of how many drinks - "at least 5"
Reports was drinking with friends at a party Reports left party to drive home because she was
mad at her girlfriend and could not take any more
Asked about driving impaired Reports knew she was driving under the influence but did not care
Reports have driven in past after drinking, but this time she did not care if she injured herself
Followed up on impaired driving - risk for self
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Reports has had enough of life and did not care if she got hurt/died
Reports had not thought about self harm before accident
Reports since accident, not sure what to think about what she did
Asked about onset and duration of pain Reports pain started immediately after accident
Reports accident was last night Reports accident was at 10 pm
Asked about location of pain Reports pain is in right wrist
Asked about aggravating factors of pain Reports increased pain when bending or twisting
(R) wrist
Reports increased pain when trying to lift items, even small ones such as a hairbrush
Asked about treatment and relieving factors of pain
Reports rest improves pain
Reports ibuprofen has significantly reduced pain Reports wearing sling helps
Asked about characteristics of pain Reports pain is aching
Denies sharp or shooting pain
Asked about severity of pain Reports current pain level is 2/10
Reports pain without medication was 8/10
Past Medical History
Asked about existing health conditions Reports no known health problems
Asked about history of mental health Denies previous history of mental illness diagnoses
Denies past depression
Reports feeling anxious over the past six months - has not sought treatment/counseling
Reports can not deal with stress of school and life in general
Reports that she does not care what happens to her anymore (passive suicidal ideation)
Followed up on stress issues Reports stress over parental relationships Reports stress over school
Reports stress over grades
Followed up on self harm Reports no active suicidal thoughts prior to accident
Denies past suicide attempts
......................................................................................continued.....................................................................................
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