8/28/2018 Focused Exam: PTSD | In Progress Attempt | Shadow Health
Focused Exam: PTSD (Part 3 of 4)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
m
er as
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
co
documentation as you respond to the prompts at the bottom of the page.
eH w
o.
Documentation Review
rs e
ou urc
Nursing Admitting...
SBAR
Mental Status Note Student Response Model Documentation
o
SBAR 1. Situation Ms. Diaz is being seen for severe sleep issues Ms. Diaz is a 48-year-old Cuban American
aC s
and claims she is unable to rest. she has a woman who is here to establish care at our
vi y re
significant psychiatric history including a clinic.
diagnosis of PTSD at the age of 35.
2. Background moderate depression found upon screening, Ms. Diaz has a history of hypertension and
emtnal health professiona referral advised by the PTSD. She is overweight, having gained 20
ed d
ptsd screening pounds over the past two years. She has
difficulty sleeping due to anxiety and nightmares.
ar stu
She has suicidal thoughts at times but has never
tried to take her life. She is not having suicidal
thoughts currently.
sh is
3. Assessment severe sleep issues, moderate depression, ptsd Ms. Diaz' blood pressure is elevated (142/90);
she did take losartan 100 mg this morning. Her
Th
weight is 181 (BMI 31.6). She does not exercise
as much as before and eats most of her meals
as carry-out. She continues to struggle with
anxiety, depressed mood, and sleep disturbance
due to nightmares. She takes bupropion 150 mg
b.i.d. and buspirone 15 mg b.i.d. for mood and
anxiety as prescribed.
4. consult mental health professional, follow doctor Based on my assessment, I recommend:
Recommendati order care plan • A referral to the clinic mental health provider to
on address PTSD and stress management.
Addressing those may help to improve sleep
and depressed mood.
• I recommend a low fat, low salt diet, low sugar
diet to manage weight, glucose, and blood
pressure. A referral to the clinic dietician will
help to formulate a diet.
https://www.coursehero.com/file/38097437/Focused-Exam-PTSD-In-Progress-Attempt-Shadow-Health-s-barpdf/
https://wgu.shadowhealth.com/assignment_attempts/3743701 1/3
Focused Exam: PTSD (Part 3 of 4)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
m
er as
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
co
documentation as you respond to the prompts at the bottom of the page.
eH w
o.
Documentation Review
rs e
ou urc
Nursing Admitting...
SBAR
Mental Status Note Student Response Model Documentation
o
SBAR 1. Situation Ms. Diaz is being seen for severe sleep issues Ms. Diaz is a 48-year-old Cuban American
aC s
and claims she is unable to rest. she has a woman who is here to establish care at our
vi y re
significant psychiatric history including a clinic.
diagnosis of PTSD at the age of 35.
2. Background moderate depression found upon screening, Ms. Diaz has a history of hypertension and
emtnal health professiona referral advised by the PTSD. She is overweight, having gained 20
ed d
ptsd screening pounds over the past two years. She has
difficulty sleeping due to anxiety and nightmares.
ar stu
She has suicidal thoughts at times but has never
tried to take her life. She is not having suicidal
thoughts currently.
sh is
3. Assessment severe sleep issues, moderate depression, ptsd Ms. Diaz' blood pressure is elevated (142/90);
she did take losartan 100 mg this morning. Her
Th
weight is 181 (BMI 31.6). She does not exercise
as much as before and eats most of her meals
as carry-out. She continues to struggle with
anxiety, depressed mood, and sleep disturbance
due to nightmares. She takes bupropion 150 mg
b.i.d. and buspirone 15 mg b.i.d. for mood and
anxiety as prescribed.
4. consult mental health professional, follow doctor Based on my assessment, I recommend:
Recommendati order care plan • A referral to the clinic mental health provider to
on address PTSD and stress management.
Addressing those may help to improve sleep
and depressed mood.
• I recommend a low fat, low salt diet, low sugar
diet to manage weight, glucose, and blood
pressure. A referral to the clinic dietician will
help to formulate a diet.
https://www.coursehero.com/file/38097437/Focused-Exam-PTSD-In-Progress-Attempt-Shadow-Health-s-barpdf/
https://wgu.shadowhealth.com/assignment_attempts/3743701 1/3
