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Shadow Health anxiety disorder
Mental Health Concepts in Nursing
Keiser University
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Patient: John Larsen – Anxiety and Panic Attack with SBAR and assessment
Chief Complaint Finding: Established chief complaint
Finding: Reports that he felt like he was "smothering" - sense of chest pressure (Found) Where do you feel the smothering sensation? Finding: Reports feeling rapid heartbeat (Found)
Can you describe the smothering sensation Reports sweating and shivering Example Question: Can you describe the smothering sensation? Finding: Reports shortness of breath Example Question: Do you ever get short of breath?
History of Present Illness Finding: Asked about onset and duration of symptoms Finding: Reports feeling started last night Example Question: When did the smothering sensation start? Finding: Reports feeling began at 3 am Example Question: When did the smothering sensation start? Finding: Reports that feeling has been constant since onset Example Question: Has the smothering sensation been constant? Finding: Asked about aggravating factors of symptoms Finding: Reports that movement or anything besides resting seems to make the symptoms worse Example Question: What makes the smothering sensation worse? Finding: Asked about relieving factors of symptoms
Finding: Reports trying to take deep breaths Example Question: What makes the smothering sensation better? Finding: Reports resting to try to feel calmer How do you treat your symptoms?
Anxiety Screening Finding: Asked about anxiety Finding: Reports excessive worry Example Question: Have you been unreasonably worried? Finding: Reports worry frequency as occurring more days that not Example Question: Do you experience excessive worry more days than not? Finding: Reports excessive worry has happened for at least the last 6 months Example Question: Have you been troubled by excessive worry for the last six months? Finding: Reports unreasonable worry about work Example Question: Are you unreasonably troubled by work? Finding: Reports unreasonable worry about health Example Question: Are you troubled by unreasonable worry about your health? Finding: Reports occasionally feeling unable to control worry Example Question: Are you feeling troubled by worrying uncontrollably? Finding: Asked about restlessness Finding: Reports occasional restlessness Example Question: Are you bothered by restlessness? Finding: Reports occasionally feeling "keyed up" or "on edge" Example Question: Have you been feeling on edge lately? Finding: Denies feeling easily tired Example Question: Do you tire easily?
Finding: Asked about depression Finding: Denies depression Example Question: Do you feel depressed more days than not? Finding: Denies losing interest in life Example Question: Do you feel disinterested in life more days than not? Finding: Denies feelings of worthlessness or guilt Example Question: Do you feel worthless more days than not? Finding: Asked about impact of alcohol or drugs on anxiety Finding: Denies alcohol use caused failure to ful+ll responsibilities
Example Question: Has your use of alcohol resulted in a failure to perform responsibilities? Finding: Denies drug use caused failure to ful+ll responsibilities. Example Question: Has your use of drugs resulted in a failure to perform responsibilities? Finding: Denies alcohol use placed him in a dangerous situation Example Question: Has your alcohol use put you in danger? Finding: Denies drug use placed him in a dangerous situation Example Question: Has your drug use put you in dangerous situations? Finding: Denies alcohol use resulted in arrest Example Question: Has your use of alcohol gotten you arrested? Finding: Denies drug use results in arrest Example Question: Has your use of drugs gotten you arrested? Finding: Denies alcohol use caused problems with loved ones Example Question: Did your alcohol use continue despite causing problems with family? Finding: Denies drug use caused problems with loved ones Example Question:
Did you keep using drugs even though they cause problems with your family?
Past Medical History Finding: Asked about existing health conditions Finding: Reports hypertension Example Question: Do you have hypertension? Finding: Reports high cholesterol Example Question: Do you have high cholesterol? Finding: Reports osteoarthritis Example Question: Do you have osteoarthritis Finding: Followed up on history of mental health Finding: Denies past depression diagnosis Example Question: Do you have a history of depression? Finding: Denies past anxiety diagnosis Example Question: Have you ever had treatment for anxiety disorder? Finding: Denies past psychiatric admissions Have you had to go to a hospital for a psychiatric disorder? Finding: Followed up on hypertension diagnosis Finding: Diagnosed at age 47 Example Question: How old were you when you were diagnosed with hypertension? Finding: Reports occasionally checking BP at the pharmacy Example Question: Where do you get your blood pressure tested? Finding: Reports belief that BP is well-controlled Example Question: How is your blood pressure now? Finding: Reports typical numbers are 110/
Example Question: What is your usual blood pressure?
Denies medication for osteoarthritis Example Question: Do you take medication for osteoarthritis? Finding: Reports medication for high cholesterol Example Question: Do you take cholesterol medication? Finding: Reports taking +sh oil capsules Example Question: Do you take vitamins or supplements? Finding: Denies taking vitamins Example Question: Do you take vitamins or supplements? Finding: Denies taking herbal supplements Example Question: Do you take herbal supplements? Finding: Followed up on last dose of home medications Finding: Reports no home meds taken today Example Question: When was the last time you took any medication? Finding: Followed up on medication for cholesterol Finding: Reports taking atorvastatin ( Example Question: What cholesterol medication do you take? Finding: Reports atorvastatin dosage: 20 mg Example Question: How much Lipitor do you take? Finding: Reports atorvastatin frequency: 1x daily Example Question: How often are you taking the Lipitor? Finding: Denies atorvastatin side e7ects Example Question: Do you have any side e7ects from the Lipitor? Finding: Followed up on medication for hypertension Finding: Reports taking lisinopril
Example Question: What do you take for your blood pressure? Finding: Reports lisinopril dosage: 10 mg (Available) Example Question: How much lisinopril are you taking? Finding: Reports lisinopril frequency: 1x daily Example Question: How often do you take the lisinopril? Finding: Denies lisinopril side e7ects Example Question: Do you get any side e7ects from the lisinopril?
Family History Finding: Asked about relevant family history Finding: Reports mother had high cholesterol Example Question: How is your mother's health? Finding: Reports father died of lung cancer, had hypertension Example Question: Can you tell me about your father's health? Finding: Reports father died at age 50 Example Question: When did your father pass away?
Social History Finding: Asked about substance use Finding: Reports occasional alcohol use Example Question: Do you drink alcohol? Finding: Denies recent alcohol use Example Question: Have you had alcohol recently? Finding: Denies illicit drug use (Found) Example Question: Do you have a history of drug use? Finding: Denies taking any form of stimulant
Finding: Reports no support system Example Question: Do you have a support system?
Review of Systems Finding: Asked about general symptoms Finding: Denies fever Example Question: Have you had a fever? Finding: Denies chills Example Question: Do you get chills? Finding: Denies night sweats Example Question: Do you get night sweats? Finding: Denies weight loss Example Question: Have you lost weight? Finding: Asked about review of systems for HEENT Finding: Reports blurry vision when he gets too worried Example Question: Is your vision blurry? Finding: Denies impaired hearing Example Question: How is your hearing? Finding: Asked about review of systems for respiratory Finding: Denies cough Example Question: Do you have a cough? Finding: Denies dyspnea on exertion Example Question: Do normal activities make you short of breath? Finding: Denies wheezing Example Question: Are you wheezing?
Finding: Asked about review of systems for cardiovascular Finding: Reports palpitations Example Question: Do you have heart palpitations? Finding: Denies chest pain Example Question: Do you have chest pain? Finding: Denies edema Example Question: Have you noticed swelling anywhere? Finding: Denies claudication (Available) Example Question: Do you get cramps? Finding: Asked about review of systems for skin, hair, and nails Finding: Denies changes in hair Example Question: Has the hair on your head changed? Finding: Denies changes in skin Example Question: Has your skin changed? Finding: Denies pruritus or easy bruising Example Question: Have you been bruising easily? Finding: Denies pigmentation changes Example Question: Has your skin changed color? Finding: Denies rashes Example Question: Do you get rashes? Finding: Asked about review of systems for gastrointestinal Finding: Denies nausea Example Question: Have you been nauseated? Finding:
Denies syncope, dizziness, fainting, or vertigo Example Question: Have you been dizzy? Finding: Denies changes in coordination Example Question: Have you had problems with coordination? Finding: Denies changes in memory Example Question: Have you had changes in memory? Finding: Denies recent falls Example Question: Have you fallen recently? Finding: Asked about review of systems for psychological Finding: Reports recent mood changes Example Question: Has your mood changed recently? Finding: Denies hallucinations Example Question: Do you ever see things that are not there? Finding: Denies suicidal ideation or self-harm
ED Nursing Note
Student
Response
Model Documentation
Chief
Complaint
(No
Documentation
Made)
Mr. Larsen is a 48-year-old White man who presented to the ED
at 6 AM with a perceived cardiac complaint; he reports being
exhausted, scared and unable to relax from last night.
History of
Present
Illness
(No
Documentation
Made)
Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the ED
this morning with complaints of exhaustion, anxiety, terror, and
tachycardia which started last night 3 AM. Patient reports that the
worry has been around since he was diagnosed with HTN (a year
ago), but becomes worse last night. He states that he feels like he
is choking, his body is sweating, shivering and he has been unable
to control his fear since 3 AM. He says that he is scared about
everything, especially his hypertension; he tried to take a deep
breath several times to feel calm but did not work. He states that
he came to the ED because he thought he was having a heart
attack from his hypertension. He says that the anxiety causes him
Student
Response
Model Documentation
to skip work, prevents social interaction and that it a7ects his
concentration and sleeping patterns. He denies any chest pain,
fever, mood changes, or suicidal thoughts.
Allergies (No
Documentation
Made)
Codeine
Past Medical
History
(No
Documentation
Made)
HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia since age 45
Past Surgical
History
(No
Documentation
Made)
To t a l k n e e r e p l a c e m e n t a g e 4 8
Medication
History
(No
Documentation
Made)
Atorvastatin 20 mg P. daily for high cholesterol. Last dose:
yesterday Lisinopril 10 mg P. daily for hypertension. Last dose:
yesterday Fish oil 1 tab daily for high cholesterol. Last dose:
yesterday
Family
History
(No
Documentation
Made)
Mother, living, high cholesterol Father died of lung cancer, had
HTN, deceased age 50 No known family history of mental
illness
Social
History
(No
Documentation
Made)
Employment: Currently employed as a postal clerk. Marital Status:
Single, has no children, living alone. Tobacco: He denies past or
present tobacco use. Alcohol/Illicit Drug Use: He drinks a beer or
two on the weekend, he denies any illicit drug use.
Review of
Relevant
Systems
(No
Documentation
Made)
GENERAL: Fatigue, and diaphoresis. Negative for fever, night
sweats, or purposeful changes in weight. RESPIRATORY: Shortness
of breath. CARDIOVASCULAR: Palpitations. Negative for chest pain,
or edema. NEUROLOGICAL: Reports weakness. Negative for
fainting, numbness/tingling, dizziness, frequent headaches, falls,
or changes in coordination or memory. PSYCHOLOGICAL: Anxiety,
changes in concentration, and sleeping pattern. Denies
depression, suicidal thoughts
Mental Status Note
Student Response Model Documentation
the interlocking shapes correctly.
Insight demonstrates
awareness of illness
and willingness to
seek treatment
Mr. Larsen displays a partial or unclear awareness
of his anxiety, but is beginning to come around to
the idea of having anxiety. He shows some
willingness to seek treatment.
Judgment demonstrate good
judgment
Mr. Larsen's judgement is intact. His response to the
"stamped envelope" scenario is appropriate.
SBAR
Student Response Model Documentaon
1. Situaon I have pt, John Larsen, 48 year old
male, complaints of chest pressure,
shortness of breath, diaphoresis, and
tachycardia. He is diagnosed for
generalized anxiety disorder with panic
a!ack episode
Mr. Larsen is 48-year-old White male
admi!ed to the ED today presen(ng with a
panic a!ack from generalized anxiety
disorder.
2. Background Mr. Larson lives alone. His past medical
history is having hyperten(on. H e was
diagnosed when he was 47. He's taking
Lisinopril for his high BP. He also have high
cholesterol, he taking atrovasta(n. He
taking -sh oils as well. We gave him Prozac
here for his anxiety. He's allergic to
codiene
Mr. Larsen has a history of HTN, hyperlipidemia,
and osteoarthri(s. He came to the ER today for a
panic a!ack that is happening for the -rst (me. He
was anxious since he was diagnosed with
hypertension. The anxiety has been worsening for
the last 6 months. He was skipping work, and was
fearful at all (mes. His treatment plans related to
this issue to date includes labs, ECG to rule out
physical condi(ons, and an(-anxiety medica(ons.
3. Assessment Pa(ent s(ll feeling smotheres, like having
heart a!ack, pressure on his chest, labored
breathing, swea(ng, tachycardia, muscle
tensions. His BP is 125/88, O2 satura(on of
99%, RR of 17bpm, heart rate 922 bpm.
GAD-7 screening score of 14 (moderate
anxiety). Sinus rhythm regular and no ST
segment eleva(on
Mr. Larsen was restless and anxious. He has
normal ECG readings and lab values except for
his glucose and lipids. A?er he was calmed
down, his vitals returned to within normal
ranges. The pa(ent has been given Prozac 20 mg
orally, and he felt be!er right a?er, ci(ng
possible placebo eAect.
4.
Recommendaon
Needs follow-up meds for his anxiety.
Referral to pscyhotherapy or CBT. Also,
some educa(on for his diet. Low-salt diet,
and educa(on about the importance of
Based on my assessment, I recommend the
following things: • Stay with the pa(ent un(l he
is completely relaxed • Contact provider to
schedule an appointment with a psychiatrist as
Student Response Model Documentaon
exercise in his life. soon as possible • Educate the pa(ent about
anxiety and panic disorders • Educate the pa(ent
on how to diAeren(ate between physical and
psychological symptoms • Educate the pa(ent on
relaxa(on techniques such as deep breathing
exercises
Shadow Health anxiety disorder
Course: Mental Health Concepts in Nursing
University: Keiser University
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