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.
Upon assessment, Mr. Adams’ indicated he was having headaches and sensitivity to light, which
could be related to his concussion or PTSD. During his Mini-cog assessment, he wasn’t able to
remember all of the words I told him to remember.
His symptoms of PTSD include not being able to relax (feeling like he needs to stay alert to
protect his family), light and loud noises affecting him, and needing to know where all of the
exits are located.
2. Identify and document key nursing diagnoses for Mr. Adams.
Ineffective coping, impaired mood regulation, risk for PTSD
3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this
care.
Before starting my assessments, I made sure it was okay for his wife to stay in the room. I
peformed a Mini-cog assessement, ACE assessment, and a PTSD screening. He kept his sun
glasses on the whole time because he stated the lights hurt his head. When I was asking him
questions related to the noted assessments, he stated that he has been having a harder time
sleeping, difficulty with loud noised, he has been more emotional and irritable, and just “doesn’t
feel right”. He responded well, but seemed overwhelmed with all of the questions.
4. Document instances of therapeutic communication and Mr. Adams’ response to this intervention.
Mr. Adams at one point wanted his wife to answer the questions, so I asked why and he was able
to elaborate and explain how he was feeling at that moment. I also used therapeutic
communication whenever I provided support to the wife and the patient.
5. Document the patient teaching related to posttraumatic stress disorder and concussion, as well as
medications, that you provided to Mr. Adams and his wife before discharge.
I told the patient and his wife that the doctor would be in to talk with him about PTSD, but that
going to support groups that include other veterans that have been through similar things would
be very beneficial for him. I also taught them that some of the symptoms for a concussion are
similar to those of PTSD.
6. Document your handoff report in the SBAR format to communicate Mr. Adams’ future needs.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
This study source was downloaded by 100000835004878 from CourseHero.com on 02-07-2022 15:46:28 GMT -06:00
https://www.coursehero.com/file/65055567/RandyAdams-Documentationdocx/
Documentation Assignments
1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and
symptoms of posttraumatic stress disorder.
Upon assessment, Mr. Adams’ indicated he was having headaches and sensitivity to light, which
could be related to his concussion or PTSD. During his Mini-cog assessment, he wasn’t able to
remember all of the words I told him to remember.
His symptoms of PTSD include not being able to relax (feeling like he needs to stay alert to
protect his family), light and loud noises affecting him, and needing to know where all of the
exits are located.
2. Identify and document key nursing diagnoses for Mr. Adams.
Ineffective coping, impaired mood regulation, risk for PTSD
3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this
care.
Before starting my assessments, I made sure it was okay for his wife to stay in the room. I
peformed a Mini-cog assessement, ACE assessment, and a PTSD screening. He kept his sun
glasses on the whole time because he stated the lights hurt his head. When I was asking him
questions related to the noted assessments, he stated that he has been having a harder time
sleeping, difficulty with loud noised, he has been more emotional and irritable, and just “doesn’t
feel right”. He responded well, but seemed overwhelmed with all of the questions.
4. Document instances of therapeutic communication and Mr. Adams’ response to this intervention.
Mr. Adams at one point wanted his wife to answer the questions, so I asked why and he was able
to elaborate and explain how he was feeling at that moment. I also used therapeutic
communication whenever I provided support to the wife and the patient.
5. Document the patient teaching related to posttraumatic stress disorder and concussion, as well as
medications, that you provided to Mr. Adams and his wife before discharge.
I told the patient and his wife that the doctor would be in to talk with him about PTSD, but that
going to support groups that include other veterans that have been through similar things would
be very beneficial for him. I also taught them that some of the symptoms for a concussion are
similar to those of PTSD.
6. Document your handoff report in the SBAR format to communicate Mr. Adams’ future needs.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
This study source was downloaded by 100000835004878 from CourseHero.com on 02-07-2022 15:46:28 GMT -06:00
https://www.coursehero.com/file/65055567/RandyAdams-Documentationdocx/
