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Shadow Health® │ Digital Clinical Experiences™ from Elsevier documentation
Course: Nurs Mental Illness (NURS 226)
4 Documents
Students shared 4 documents in this course
University: Indiana State University
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Focused Exam: Schizophrenia Results | Turned In
FALL 2023 NURC 338: Mental Health, NURC 338
Return to Assignment (/assignments/842049/)
Documentation / Electronic Health Record
Nursing Admitting Note
Student Documentation Model Documentation
Chief Complaint
Patient c/o hallucination and admit to having suicide
thoughts.
Eric Ford is a 28-year-old African American man who
was brought to the ER by his mother for acute audito
hallucinations and paranoia.
History of Present Illness
Patient has been diagnose with schizophrenia when he
was 23.
Eric Ford has a history of chronic paranoid
schizophrenia, onset age 23. Three previous
hospitalizations with the most recent 2 years ago.
History significant for a suicide attempt by overdose
age 25, requiring ICU admission. Patient has not be
sleeping or eating well. His mother reports that he ra
out of medication 9 days ago and is concerned for h
safety.
He denies suicidal intent and states that he sometim
listens to music to avoid paying attention to the voice
Denies homicidal ideation. Does not initiate
conversation. Presence of + auditory command
hallucinations. Appears to be limited in ability to
complete activities of daily living, disheveled with so
clothing.
Allergies
(No Documentation Made) NKA / NKDA
Past Medical History
(No Documentation Made) Schizophrenia, since age 23
Your Results Lab Pass (/assignment_attempts/15175216/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
Care Plan
Program Competency Progress
Reflections
Student Survey
Flowsheets Documentation
