Focused Exam_ Schizophrenia _ In Progress Attempt _ Shadow Health.

Focused Exam: Schizophrenia (Part 2 of 2) Therapeutic Intervention III - Winter 2020, NUR 304 Return to Assignment (/assignments/288273/) Reflections Activity Description: Reflective writing develops your clinical re ...

Focused Exam: Schizophrenia (Part 2 of 2) Therapeutic Intervention III - Winter 2020, NUR 304 Return to Assignment (/assignments/288273/) Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p Documentation Review Nursing Admitting Note Student Response Model Documentation Chief Complaint Voices telling patient that his life is ending soon. Eric Ford is a 28-year-old African American man who was brought to the ER by his mother for acute auditory hallucinations and paranoia. History of Present Illness Schizophrenia diagnosed at age 23. 4 total hospitalizations related to schizophrenia Eric Ford has a history of chronic paranoid schizophrenia onset age 23. Three previous hospitalizations with the mo recent 2 years ago. History significant for a suicide attem overdose at age 25, requiring ICU admission. Patient has been sleeping or eating well. His mother reports that he r out of medication 9 days ago and is concerned for his saf He denies suicidal intent and states that he sometimes lis to music to avoid paying attention to the voices. Denies homicidal ideation. Does not initiate conversation. Presen + auditory command hallucinations. Appears to be limited ability to complete activities of daily living, disheveled with soiled clothing. Allergies No known allergies NKA / NKDA Past Medical History No known health conditions besides schizophrenia (diagnosed at 23 y/o) 3 previous hospitalizations because of schizophrenia at ages 23, 25, 26. Schizophrenia, since age 23 Nursing Admitting... Mental Status Note SBAR This study source was downloaded by 100000831988016 from CourseHero.com on 05-06-2022 15:06:43 GMT -05:00 https://www.coursehero.com/file/53484001/1-Focused-Exam-Schizophrenia-In-Progress-Attempt-Shadow-Healthpdf/ 1/4/2020 Focused Exam: Schizophrenia | In Progress Attempt | Shadow Health https://app.shadowhealth.com/assignment_attempts/5886664 2/3 Student Response Model Documentation Past Surgical History No reported surgeries No previous surgeries Medication History Schizophrenia medication -Risperdal (2x a day), not currently taking b/c of financial difficulty Insomnia medication -trazadone (1x daily) Risperdal 2 mg P.O. b.i.d. For Psychotic Symptoms Trazodone 25 mg P.O. Q HS for Insomnia Family History Lives with mother, who is reportedly healthy Unsure about father's health status No known family related illness No known history of family mental illness Social History Limited drinking, reports only drinking 1x beer in social settings. Doesn't like drinking or the effects of over drinking. Smokes cigarettes regularly; 1x pack/day Occupation and Education: Employed as a stocker at a grocery store. Patient completed high school, currently in college studying Audio Engineering. Reports missing sch and work for the past week. Marital Status: Unmarried, no children-states he is in a monogamous relationship with girlfriend Substance Use: Smokes cigarettes, 1 ppd since age 16. Consumes 1-2 alcoholic drinks per week. No illicit drug us Review of Relevant Systems (No Documentation Made) GENERAL: Poor Hygiene noted. No evidence of distinguishing marks, scars, tattoos. Wearing soiled cloth Negative for fever, chills, night sweats. Reports difficulty f asleep, mid-night awakening. RESPIRATORY: Negative for shortness of breath, cough, wheezing. CARDIOVASCULAR: Negative for chest pain, palpitations edema. GASTROINTESTINAL: Denies nausea, denies vomiting, constipation, diarrhea. Positive for diminished appetite in week. NEUROLOGICAL: Negative for weakness, frequent headaches, dizziness, falls, or changes in coordination. + perceptual disturbances including auditory hallucinations paranoid delusions. INTEGUMENTARY: Skin, pink, warm, intact. Negative for changes hair, or nails. Negative for rashes, pigmentation changes, pruritus, or easy bruising. MUSCULOSKELETAL: Negative for recent injuries, joint erythema, or edema of joints.