Randy Adams_Mental Health Case_2022/2023 | RNSG 1443 Mental Health Case_Documentation_Graded A

Mental Health Case: Randy Adams Documentation Assignments 1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder. Mr. Adams presents with headache and sensitivity to light and noise. His memory has also been impaired, demonstrated by his ability to recall two of the three words he was asked to remember. He states that his sleeping has been getting better. 2. Identify and document key nursing diagnoses for Mr. Adams. - Disturbed senesoy perception related to head injury as evidenced by sensitivity to light and noise - Ineffective coping related to traumatic event as evidenced by client stating he “tries not to think about the accident” - Anxiety related to traumatic event as evidenced by client exhibit restless behavior, appearing tense and asking to stand during assessment 3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care. Feedback Log 0:49 The patient said: I'm not sure what I would do without Joy.nYou answered: It sounds like your relationship with your wife is very important to you. nYou used the therapeutic technique of encouraging expression. 0:50 You washed your hands. 0:57 You identified the patient. 1:10 You asked if the patient had any known allergies. 1:25 You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with him to get an understanding of this. 1:42 The patient said: The doctors at the VA want me to talk about all the things from the past that make me uncomfortable. Talking about the past won't help.nYou answered: Are you uncomfortable when you talk about the past? nYou used the therapeutic technique of making observations. 1:48 You asked the patient: Over the past year, when did you feel your best? The patient said: I felt my best when I was with my team in Afghanistan. It was appropriate to ask the patient about when he felt his best. 2:09 You asked the patient: Do you have nightmares or vivid dreams on a regular basis? 2:25 The patient said: I have these dreams; I can't remember them, but when I wake up, my heart is racing.nYou answered: What seems to lead up to you having these dreams? nYou used the therapeutic technique of placing the event in time or sequence. 2:30 You supported the patient's wife about coming home to toddlers. 2:53 You asked the patient: Approximately how many hours of sleep do you get each night? 3:02 The patient said: I really don't need much sleep.nYou answered: Are you saying that you don't sleep well? nYou used the therapeutic technique of verbalizing the implied. 3:09 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? 3:20 The patient said: Sometimes it's like I'm full of all this energy but I don't know what to do with it.nYou answered: When does this happen? nYou used the therapeutic technique of placing the event in time or sequence. 3:29 You asked the patient: Do you have any pain? 3:40 The patient said: The lights; they make my headache worse.nYou answered: Intolerance to light is a common symptom related to a head injury. nYou used the therapeutic technique of giving information. - - - - - - Continued