LECTPEREZ
Focused Exam: Alcohol Use Disorder (Part 2 of 3)
BSN Psychiatric and Mental Health Nursing - Feb 2020
Return to Assignment (/assignments/306546/)
Reflections
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 proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p
Documentation Review
Nursing Admitting... SBAR
Mental Status Note
Student Response Model Documentation
SBAR 1. Situation Rachel Adler is a 20-year-old female motor vehicle accident Rachel Adler is a 20-year-old White woman admitted from
victim with a sprained right wrist. Was admitted with a high ER last night after a MVA related to alcohol use. She
blood alcohol level. Patient does not acknowledge problem sustained a (R) wrist sprain during the accident and voice
with alcohol. lack of concern for her personal safety, which is why they
admitted her to the psych unit.
2. Background Patient was drinking at a party last night when she became Ms. Adler has a history of alcohol use, but no previous ove
upset with a friend. She had approximately five drinks but is suicidal attempts. She reports a great deal of stress relate
unsure. She drove away intoxicated and became involved in a college, her relationship with her mother, and self-esteem
MVA at approximately 2200 that caused a sprained right wrist. issues surrounding academic performance. After her accid
Current pain is mild, constant ache in right wrist. Pain is last evening she stated she did not care what happened to
aggravated with movement and lifting of objects. Ibuprofen and her. Based on her reckless behavior and intoxication she w
sling improve pain levels. Patient admits to ideas of self-harm admitted for treatment of ETOH use and suicidal ideation.
when driving last night, feeling as though "it would be easier if
it was all over." Patient was aware she was endangering
others, but she has no desire to harm others. Patient has not
tried to cut down on drinking. Believes people don't know or
don't care that she drinks. Drinks alcohol to "let go" when she
feels "overwhelmed." Drinking makes her "feel better." She
denies drinking first thing in the morning. She has a peanut
allergy - experiences mouth and throat pruritis.
3. Assessment The patient has mild pain in right wrist. No other adverse Ms. Adler had a pain report of 8/10 of her (R) wrist. She
conditions were noted. Patient tests positive for possible experienced relief with ibuprofen while in the ER and after
alcohol abuse. Patient has had suicidal ideations. being medicated she rates her pain as 2/10. She gets anx
when questioned about her alcohol use and her ability to s
safe. Other than the wrist sprain, she is in good general
health. She does have a peanut allergy, but no medication
allergies.
4. Recommendation Patient should be monitored for suicidal thoughts and safety. Based on my assessment, we need to follow up today with
Patient should be educated on the risks of alcohol and the completing an assessment for suicidal ideation and make
dangers of driving intoxicated. she is on the roster for q 15 min safety checks. As far as h
therapy for today, there is a team meeting at 10 AM to dis
her care plan and she should meet with the therapist at 11
The unit AA meeting is scheduled at 4 PM and she should
attend that session as well.
What did you learn about assessing a patient with mental illness? How can you apply this
to your clinical practice when working with these types of patients?
This study source was downloaded by 100000843746907 from CourseHero.com on 04-27-2022 19:30:43 GMT -05:00
https://www.coursehero.com/file/60520747/Focused-Exam-Alcohol-Use-Disorder-In-Progress-Attempt-Shadow-Health-SBARpdf/
Focused Exam: Alcohol Use Disorder (Part 2 of 3)
BSN Psychiatric and Mental Health Nursing - Feb 2020
Return to Assignment (/assignments/306546/)
Reflections
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 proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p
Documentation Review
Nursing Admitting... SBAR
Mental Status Note
Student Response Model Documentation
SBAR 1. Situation Rachel Adler is a 20-year-old female motor vehicle accident Rachel Adler is a 20-year-old White woman admitted from
victim with a sprained right wrist. Was admitted with a high ER last night after a MVA related to alcohol use. She
blood alcohol level. Patient does not acknowledge problem sustained a (R) wrist sprain during the accident and voice
with alcohol. lack of concern for her personal safety, which is why they
admitted her to the psych unit.
2. Background Patient was drinking at a party last night when she became Ms. Adler has a history of alcohol use, but no previous ove
upset with a friend. She had approximately five drinks but is suicidal attempts. She reports a great deal of stress relate
unsure. She drove away intoxicated and became involved in a college, her relationship with her mother, and self-esteem
MVA at approximately 2200 that caused a sprained right wrist. issues surrounding academic performance. After her accid
Current pain is mild, constant ache in right wrist. Pain is last evening she stated she did not care what happened to
aggravated with movement and lifting of objects. Ibuprofen and her. Based on her reckless behavior and intoxication she w
sling improve pain levels. Patient admits to ideas of self-harm admitted for treatment of ETOH use and suicidal ideation.
when driving last night, feeling as though "it would be easier if
it was all over." Patient was aware she was endangering
others, but she has no desire to harm others. Patient has not
tried to cut down on drinking. Believes people don't know or
don't care that she drinks. Drinks alcohol to "let go" when she
feels "overwhelmed." Drinking makes her "feel better." She
denies drinking first thing in the morning. She has a peanut
allergy - experiences mouth and throat pruritis.
3. Assessment The patient has mild pain in right wrist. No other adverse Ms. Adler had a pain report of 8/10 of her (R) wrist. She
conditions were noted. Patient tests positive for possible experienced relief with ibuprofen while in the ER and after
alcohol abuse. Patient has had suicidal ideations. being medicated she rates her pain as 2/10. She gets anx
when questioned about her alcohol use and her ability to s
safe. Other than the wrist sprain, she is in good general
health. She does have a peanut allergy, but no medication
allergies.
4. Recommendation Patient should be monitored for suicidal thoughts and safety. Based on my assessment, we need to follow up today with
Patient should be educated on the risks of alcohol and the completing an assessment for suicidal ideation and make
dangers of driving intoxicated. she is on the roster for q 15 min safety checks. As far as h
therapy for today, there is a team meeting at 10 AM to dis
her care plan and she should meet with the therapist at 11
The unit AA meeting is scheduled at 4 PM and she should
attend that session as well.
What did you learn about assessing a patient with mental illness? How can you apply this
to your clinical practice when working with these types of patients?
This study source was downloaded by 100000843746907 from CourseHero.com on 04-27-2022 19:30:43 GMT -05:00
https://www.coursehero.com/file/60520747/Focused-Exam-Alcohol-Use-Disorder-In-Progress-Attempt-Shadow-Health-SBARpdf/
