Focused Exam:Alcohol Use Disorder/Alcohol Abuse;Documentation(Mental Status Note+SBAR)

1/14/2020 Focused Exam: Alcohol Use Disorder | In Progress Attempt | Shadow Health https://app.shadowhealth.com/assignment_attempts/5919539 1/3 Focused Exam: Alcohol Use Disord er (Part 2 of 3) Therapeutic Intervention III - Winter 2020, NUR 304 R eturn to Ass ignment (/assignments/288277/) Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor i nsight 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 Nursin g Admitting.. . Mental Status Note SBAR Mental Status Note Student Response Model Documentation Appearance Patient will not make direct eye contact and postures shows tension and rigidity. Patients clothing is clean and intact and patient shows signs of appropr iate level of grooming and selfcare Ms. Adler is a 20 -year-old White woman of average heigh average weight. She exhibits indirect eye contact during t examination, and a worried expression. Her posture was tense. When she arrived, Ms. Adler’s clothing was approp to her age and worn appropria tely. Appropriate hygiene a grooming. Attitude Patient is suspicious, guarded, and evasive. Overall is compliant with interview but demonstrates poor attitude about self Ms. Adler displays no excessive liveliness or intense mannerisms. She has a blunt affect. She is cooperative w the medical staff and forthcoming with information about h current mental state. Speech Patient has expected rate of speech, but with a loud speech volume and no appreciable issues with articulation Ms. Adler’s speech characteristics display the expected complexity for her age, education level, and general abilit Presents no observable articulation problems. Her speech slow, hesitant, and spoken at a low volume. Mood and Affect Patient has a stable mood and a balanced affect. Ms. Adler expresses a moderate level of anxiety over her current circumstances, stating that the last six months of life have been stressful, and that she has been increasing anxious. She states that she was overwhelmed. Her responses seem appropriate to the situation, and althoug is upset, her emotions are with in a stable range. Shadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience! (/site_notice_dismissals?from_flash=true&site_not i 1/14/2020 Focused Exam: Alcohol Use Disorder | In Progress Attempt | Shadow Health https://app.shadowhealth.com/assignment_attempts/5919539 2/3 Student Response Model Documentation Thought Process Patient shows no signs or presence of thought disturbances Ms. Adler’s pattern of thinking is coherent and logical. Sh offers relevant information about her circumstances and exhibits a normal continuity of thought. Observed no pote disordered behaviors. Observed no rhyming, clang association, or puns. Thought Content Patient presents suicidal ideations and wanting to be dead. Patient understands reason for hospital admission and injury and wishes she'd 'been hurt more'. Patient has no desire to cut down drinking and has black out twice in the past month from drinking Patient has driven drunk several times and believes it is acceptable because her 'friends also do it' Ms. Adler displays passive suicidal ideation and expresse that she does not care if she lives or dies. Ms. Adler does express any active suicidal ideation or plans for ending he life. She says she has never attempted suicide or planned suicide attempt. Ms. Adler seems to be under stress from school and her relationship with her mother. She is deeply distraught over her DUI and the circumstances that broug her to the ER. Perceptual Disturbances Patient presents no perceptual disturbances Ms. Adler displays no evidence of delusions or observabl abnormal tendencies during the exam. There is no eviden hallucinations or false sensory perceptions. Orientation and Level of Consciousness Patient is oriented to person, place, time, and situation A&O x4 Cognition Patient successfully completed cognition tests including serial sevens, abstract thinki ng, remote memory intact, and visuospatial ability. Normal attention and serial 7s. Normal ability for abstract reasoning. Ms. Adler seems to have a logical train of thou and is capable of understanding why she is here. Her gen intellect appears to be abo ve average. Working memory a episodic memory seem normal. Insight Patient understands but has limited awareness of illness and is unwilling to seek treatment Ms. Adler appears to be unclear in her awareness of her alcohol use. She says she drinks because of stress ors lik school and her relationship with her family. She describes drinking up to five drinks at a time three or four nights a w and expresses that the MVA the previous night was not th first time she had driven while under the influence. She sh no willing ness to seek treatment for her alcohol use. Judgment Patient shows good judgement Ms. Adler acknowledges a family history of mental illness alcohol use, but fails to connect these factors to issues wi her own excessive use of alcohol. However, her response the "s tamped envelope" scenario shows that she is capab using good judgment. What did you learn about assessing a patient with mental illness? How can you apply this https:// .......... ............................ /file/ 5to34y8o39u6r5c/2li-nFioccaulsepdr-aEcxtaimce-Awlchoehonl-wUsoer-kDinisgordweirt-hInt-hPreosgerestys-pAettsemopftp-Sahtaiedonwts-H?ealthpdf/