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Focused Exam Alcohol Use Disorder Completed Shadow Health
Mental Health Nursing (NU 309)
Herzing University
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Focused Exam: Alcohol Use Disorder Results | Turned In
Mental Health Nursing - January 2021, (2021_spring_c16_term)__nu309ka
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Subjective Data Collection: 51 of 51 (100%)
Chief Complaint
History of Present Illness
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
Reflections
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Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yie better patient data. The following details are facts o patient's case.
Established chief complaint and reason for admittance
Reports car accident Reports injury Reports passive suicidal ideation
Followed up on details of car accident Reports loss of consciousness Reports being unsure of how the accident happened Reports wearing seatbelt Reports being the driver - no other passengers in car Reports was told she would get a ticket for DUI
Followed up on alcohol use just prior to car accident
Reports drinking before accident Reports being unsure of how many drinks - "at least 5" Reports was drinking with friends at a party Reports left party to drive home because she wa mad at her girlfriend and could not take any more
Asked about driving impaired Reports knew she was driving under the influenc but did not care Reports have driven in past after drinking, but thi time she did not care if she injured herself
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Support
Past Medical History
Followed up on impaired driving - risk for self harm
Reports has had enough of life and did not care i she got hurt/died Reports had not thought about self harm before accident Reports since accident, not sure what to think about what she did
Asked about onset and duration of pain Reports pain started immediately after accident Reports accident was last night Reports accident was at 10 pm
Asked about location of pain Reports pain is in right wrist
Asked about aggravating factors of pain Reports increased pain when bending or twisting (R) wrist Reports increased pain when trying to lift items, even small ones such as a hairbrush
Asked about treatment and relieving factors of pain
Reports rest improves pain Reports ibuprofen has significantly reduced pain Reports wearing sling helps
Asked about characteristics of pain Reports pain is aching Denies sharp or shooting pain
Asked about severity of pain Reports current pain level is 2/ Reports pain without medication was 8/
Asked about existing health conditions Reports no known health problems
Asked about history of mental health Denies previous history of mental illness diagnoses Denies past depression Reports feeling anxious over the past six months has not sought treatment/counseling Reports can not deal with stress of school and lif in general Reports that she does not care what happens to her anymore (passive suicidal ideation)
Followed up on stress issues Reports stress over parental relationships Reports stress over school Reports stress over grades
Followed up on self harm Reports no active suicidal thoughts prior to accident Denies past suicide attempts
Followed up on confusion about life/death Reports feeling it may be better if she "does not have to put up with the stress of life anymore"
Is a junior Reports being a good student Reports majoring in physics
Asked about work Denies having a job outside of school
Asked about family and support system Describes relationship with parents as "decent"
Reports arguing with her mother more frequently as of late Reports mother is very judgemental and has high expectations Reports interacts minimally with mother and turns to father for support Reports has one sibling (brother) who lives out of state - sees him on holidays Reports feeling like she has few close friends at school
Asked about living situation Reports living in a dorm
Reports living with one roommate
Asked about exercise Reports exercising 3 - 4 days a week
Prefers running Occasionally goes to the gym to workout
Asked about diet Reports typically skipping breakfast Reports fruit or salad for typical lunch Reports a small dinner, typically a sandwich
Asked about appetite Reports loss of appetite
Asked about last menstrual period Reports LMP was 2 weeks ago
Asked about sexual activity Reports not currently sexually active
Reports last sexual activity was 3 months ago Reports being single Reports is on birth control pills and practices safe sex Denies STDs, tested 3 months ago when getting new prescription for birth control pills Denies any past pregnancies or ABs
Asked about substance use Reports alcohol use
Denies illicit drug use Denies use of tobacco and nicotine products
Followed up about alcohol use Reports frequent alcohol use Reports drinking beer or wine coolers
Followed up on frequency of alcohol use Reports drinking 3 - 4 nights a week Reports drinking up to 5 drinks at a time Reports usually drinks with others, may drink alone
CAGE Assessment
Review of Systems
Followed up on passing out from drinking Reports occasionally passing out from drinking Reports passing out twice in the last month Reports has little to no memory of events prior to passing out Reports no significant injuries (prior to car accident) when passed out from drinking
Followed up on frequency of hangovers Reports feeling hungover most of the time when she drinks
Asked about cutting down on drinking Reports that she has not tried to cut down on drinking Reports when she drinks she tends to eat less
Asked about others perceptions of drinking Reports that since she mostly drinks with friends no one cares about her drinking Reports that she rarely drinks in front of parents - so they do not know how much she drinks
Asked about feelings around drinking Reports that she drinks to feel better or to feel nothing Reports her drinking does not hurt anyone, so sh does not feel bad or guilty for drinking
Asked about drinking first thing in the morning Denies drinking first thing in the morning
Asked about general symptoms Denies fever Denies chills Denies night sweats Reports occasional fatigue
Asked about review of systems for HEENT Denies impaired vision Denies impaired hearing
Asked about review of systems for respiratory Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing
Asked about review of systems for cardiovascular Denies chest pain Denies palpitations Denies edema Denies claudication
Asked about review of systems for skin, hair, and nails
Denies changes in hair Denies changes in skin Denies changes in nails Denies rashes Denies pruritus or easy bruising Denies pigmentation changes
Focused Exam Alcohol Use Disorder Completed Shadow Health
Course: Mental Health Nursing (NU 309)
University: Herzing University
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