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Focused Exam Bipolar Disorder Completed Shadow Health
Nursing Concepts III (NURS2430)
Louisiana State University
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Focused Exam: Bipolar Disorder Results | Completed
Mental Health Concepts in Nursing - January 2020, nur3525-ku_wpb_nur3525d
Return to Assignment (/assignments/303927/)
Subjective Data Collection: 62 of 69 (89%)
Chief Complaint
History of Present Illness
Your Results Turn In (/assignment_attempts/6103726/choose
Lab Pass (/assignment_attempts/6103726/lab_pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
Reflections
Indicates an item that you found. Indicates an item that is available to be found.
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 yield better patient data. The following details are facts of t patient's case.
Asked about chief complaint Reports being brought in by police
Followed up on incident Reports looking into cars for government agents chasing him Reports having been in a grocery store parking lot Reports knowing the police stopped him for running around and looking in cars Denies having hurt himself or others Denies having done anything illegal
Followed up on government agents Reports government is trying to imprison him for being enlightened Reports government sees his enlightenment as a threat to their secrets
Asked about anxiety or paranoia Denies anxiety or paranoia Reports high awareness of government agents chasing him
Asked about hallucinations Denies hallucinations
Asked about most recent substance use Reports last substance use was about four days ago
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Past Medical History
Home Medications
Reports last substance use was cocaine
Asked about recent sleep history Reports not having slept for four days
Asked about current energy levels Reports current extremely high energy
Asked about current mood Reports current euphoria
Asked about onset of energy and mood Reports high energy began a week ago Reports euphoria began a week ago
Asked about existing health conditions Reports being diagnosed with depression
Asked about typical moods Reports periods of euphoria Reports periods of depression
Asked about typical energy levels Reports periods of extremely low energy Reports periods of extremely high energy
Asked about frequency of mood changes Reports mood changes occur a couple of times a year
Asked about last period of depression Reports last depressive period ended a couple months ago Reports last depressive period was a long one
Asked about details of depression diagnosis Reports being diagnosed by psychiatrist Reports diagnosed 3 years ago
Asked about reason for seeing psychiatrist Reports being made to see the psychiatrist following a suicide attempt
Asked about how depression was treated Reports psychiatrist prescribed antidepressants
Asked about hospitalizations Reports being hospitalized after suicide attempt Reports being hospitalized 3 years ago
Asked about allergies Denies allergies
Asked about effectiveness of medication Reports antidepressants were not effective Reports antidepressants caused side effects Reports stopping the antidepressant regimen Reports not consulting a healthcare provider before stopping regimen
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Social History
Asked about fights or arguments Reports getting into arguments when angry Denies getting into physical fights
Asked about self-concept Reports extremely high self-concept
Asked about typical sleep patterns Reports typically sleeping two hours a night
Asked about changes in speed of moving or speaking
Reports being a very fast speaker and mover
Asked about racing thoughts Reports racing thoughts
Asked about pleasure and interest in typical activities
Reports very much enjoying life
Asked about ability to concentrate Reports extremely high ability to concentrate on what matters
Asked about changes in productivity Reports increase in productivity for the past week
Followed up on personal projects Reports working on epic poem
Asked about changes in social activity Reports increase in social activity for the past week
Asked about changes in libido and sexual activity Reports increase in libido and sexual activity for the past week
Followed up on details of sexual activity Reports having multiple partners Reports having sex with friends and strangers Reports having rough sex Denies using condoms or contraceptives Reports having sex with women and men Denies STI symptoms Reports recent STI screening was negative
Asked about spending habits and consequences Reports spending money on drugs Reports shopping often online for rare books Reports giving money to friends Reports parents express frustration over his spending habits
Asked about financial status and occupation Denies being employed Reports parents give him money
Followed up on occupation Reports being fired from previous jobs Reports not wanting to talk about details of being fired
coursehero/file/54898118/Focused-Exam-Bipolar-Disorder-Completed-Shadow-Healthpdf/
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Asked about legal troubles Denies ever being in trouble with the law
Asked about typical substance use Denies tobacco use Reports drinking alcohol Reports typical cocaine use Denies using recreational drugs besides cocaine
Followed up on alcohol use Reports drinking 2-3 times a week Reports starting to drink at age 18 Reports drinking most when depressed Reports drinking to improve mood Reports drinking to aid sleep Denies alcohol addiction or experiencing withdrawals Denies physical side effects from alcohol use
Followed up on drug use Reports using cocaine 2-3 times a week Reports starting using cocaine eight months ago Reports enjoying the boost to mood and energy Denies cocaine addiction or experiencing withdrawals Denies side effects from cocaine use
Asked about methods of transportation Reports getting around via his car Denies driving under the influence Denies wearing seatbelt
Asked about diet and appetite Reports eating 1 small meal a day for the past week Reports typically low appetite
Asked about fluid intake Reports not keeping track of fluid intake Reports typically drinking water
Asked about caffeine intake Reports not needing caffeine for energy
Asked about patient's level of education Reports one year of college Reports being expelled from college Reports expulsion was due to poor attendance Reports poor attendance was due to depression
Asked about access to healthcare Reports parents pay for his insurance
Asked about living situation Denies having own residence Reports couch-surfing with friends or sleeping in car Reports parents won't house him due to drug use
Asked about family relationships and support system
Reports tension with parents over drug use Reports resentment toward parents for suggesting need for rehab Reports close relationships with friends
coursehero/file/54898118/Focused-Exam-Bipolar-Disorder-Completed-Shadow-Healthpdf/
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Focused Exam Bipolar Disorder Completed Shadow Health
Course: Nursing Concepts III (NURS2430)
University: Louisiana State University
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