Focused Exam_ Alcohol Use Disorder _ Completed _ Shadow Health

Focused Exam: Alcohol Use Disorder Results | Turned In Mental Health Concepts in Nursing - January 2020, nur3525-ku_wpb_nur3525d0 Return to Assignment (/assignments//) Your Results Lab Pass (/assignment_attempts//lab_pass.p Overview Transcript Subjective Data Collection: 51 of 51 (100.0%) Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. 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 This study source was downloaded by from ChoaurrmseH on 10-05-2021 09:19:45 GMT -05:00 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 ...........................................continued....................................................