Gaelle Larose
Vsim
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.
The symptoms of concussion of Mr Adams: He had a headache, and was sensitive
to light. He has his sunglasses on and did not want to take them off because it made
his heachache worse due to his sensitivity. The patient found it hard to concentrate
at times and remembering things. At times his wife had to remind him of things
.The patient was experiencing irratibility, andhad a reduced amount of sleep in the
past few weeks. His symptoms worsened with mental activity.
Posttraumatic stress disorder symptoms: Mr Adams has experiences
nerviouseness, he stated “ I cant relax, a good soldier is always prepared to act. Mr
adams has experienced things in the past from being a soldier that he does not want
to think or know about, he has tried going out of his way to forget or to stop
thinking about some of the experinces he had or that he is not happy about. The
patient walks a lot at home, and likes to make sure that the doors are locked. He
does not like to sit without seeing the exit sign. Not seeing the exit sign makes him
uncomfortable. The patient recently feels that he is not the same and feels detached
from his friends because they do not understand him now.
Cognition assessment: Patient was able to recall 2 out fo the three words I had
verbalized to him. Patient successfully drew a correct clock with the hands
showing ten past eleven
2. Identify and document key nursing diagnoses for Mr. Adams.
Patient has a concussion due to a head injury froma car accident.
Patient has symptoms of PTSD due to his service in Afghanistan.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
, Gaelle Larose
Vsim
Headache and irratibility of Mr Adams can be managed with adequate sleep
3. Referring to your feedback log, document all nursing care provided and Mr.
Adams’ response to this care.
0:00 You checked scene safety. It was correct to check scene safety in
order to maintain your own safety.
0:06 You introduced yourself.
0:54 You washed your hands.
1:03 You identified the patient.
1:18 You asked the patient: Is it OK for your wife to be here, while we
talk? It was correct to let the patient give his consent for letting his
wife be a part of the interview.
1:30 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.
1:35 You asked if the patient had any known allergies.
1:41 You performed medication reconciliation.
2:03 You assessed the respiration.
2:16 You checked the pulse oximetry.
2:33 You checked the radial pulse.
2:50 You measured the blood pressure.
3:06 You measured the temperature.
3:21 You auscultated the lung sounds.
3:33 You auscultated the heart sounds.
3:59 You checked the patient's skin.
4:25 You asked the patient: I would like to ask you a series of questions
From vSim for Nursing | Mental Health. © Wolters Kluwer.
Vsim
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.
The symptoms of concussion of Mr Adams: He had a headache, and was sensitive
to light. He has his sunglasses on and did not want to take them off because it made
his heachache worse due to his sensitivity. The patient found it hard to concentrate
at times and remembering things. At times his wife had to remind him of things
.The patient was experiencing irratibility, andhad a reduced amount of sleep in the
past few weeks. His symptoms worsened with mental activity.
Posttraumatic stress disorder symptoms: Mr Adams has experiences
nerviouseness, he stated “ I cant relax, a good soldier is always prepared to act. Mr
adams has experienced things in the past from being a soldier that he does not want
to think or know about, he has tried going out of his way to forget or to stop
thinking about some of the experinces he had or that he is not happy about. The
patient walks a lot at home, and likes to make sure that the doors are locked. He
does not like to sit without seeing the exit sign. Not seeing the exit sign makes him
uncomfortable. The patient recently feels that he is not the same and feels detached
from his friends because they do not understand him now.
Cognition assessment: Patient was able to recall 2 out fo the three words I had
verbalized to him. Patient successfully drew a correct clock with the hands
showing ten past eleven
2. Identify and document key nursing diagnoses for Mr. Adams.
Patient has a concussion due to a head injury froma car accident.
Patient has symptoms of PTSD due to his service in Afghanistan.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
, Gaelle Larose
Vsim
Headache and irratibility of Mr Adams can be managed with adequate sleep
3. Referring to your feedback log, document all nursing care provided and Mr.
Adams’ response to this care.
0:00 You checked scene safety. It was correct to check scene safety in
order to maintain your own safety.
0:06 You introduced yourself.
0:54 You washed your hands.
1:03 You identified the patient.
1:18 You asked the patient: Is it OK for your wife to be here, while we
talk? It was correct to let the patient give his consent for letting his
wife be a part of the interview.
1:30 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.
1:35 You asked if the patient had any known allergies.
1:41 You performed medication reconciliation.
2:03 You assessed the respiration.
2:16 You checked the pulse oximetry.
2:33 You checked the radial pulse.
2:50 You measured the blood pressure.
3:06 You measured the temperature.
3:21 You auscultated the lung sounds.
3:33 You auscultated the heart sounds.
3:59 You checked the patient's skin.
4:25 You asked the patient: I would like to ask you a series of questions
From vSim for Nursing | Mental Health. © Wolters Kluwer.
