Mental Health Results | Turned In
Health Assessment for Registered Nurses- Summer 1- 2020, NSG 323
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Mental Health Results | Turned In
Health Assessment for Registered Nurses- Summer 1- 2020, NSG 323
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information (https://support.shadowhealth.com/hc/en-us/articles/360009548313)
Subjective Data Collection: 37 of 44 (84.1%)
Chief Complaint
History of Present Illness
Your Results Lab Pass (/assignment_attempts/6924331/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
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found.
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available to be found.
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 yield
better patient data. The following details are facts of t
patient's case.
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
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
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
Hover To Reveal...
Hover over the Patient Data items
below to reveal important
information, including Pro Tips and
Example Questions.
Downloaded by Denis Munene (
[email protected])
lOMoARcPSD|16310140
6/10/2020 Mental Health | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6924331 2/6
Medical History
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"
Reports feeling slowed down and tired, having
trouble focusing, and generally feeling "less sharp"
Asked about anxiety symptoms 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
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 quality Reports feeling nervous and worrying about the
f
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