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Focused Exam Schizophrenia Completed Shadow Health Eric Ford Transcript
Concepts of Nursing III (BSN 346)
Nightingale College
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Focused Exam: Schizophrenia Results | Completed
ICHS - Capstone Spring 2021 - June 2021, nur2811ug
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Transcript
Started: Jul 21, 2021 | Total Time: 792 min
Gre 07/21/21 8:23 PM E
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Your Results Turn In (/assignment_attempts/10225671/cho
Reopen (/assignment_attempts/10225671/reope
Lab Pass (/assignment_attempts/10225671/lab_pass.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
Care Plan
Reflections
Interview Questions (177) Statements (17) Exam Actions (35)
Hello, I'm Precious and I'll be taking care of you today
Hey there.
Great job! This question is open-ended enough to allow the patient to respond flexibly about the symptoms bothering them and their reason for being in the hospital.
What brings you to the hospital today?
Look. I'm not crazy, OK. I've got some problems, I know, but I'm not crazy. It's these voices I get. They're everywhere and everyone and they just kept getting louder. They kept getting harsher... just awful.
Great job! This question seeks further clarification about what the patient has said without outright rejecting or validating what they are experiencing.
Can I ask who is telling you that your life is almost over?
I mean these voices I keep hearing, they keep telling me my life is almost over and I can't get them to stop. Do you hear them?
Great job! This empathetic response acknowledges the potentially frightening nature of auditory hallucinations and presents reality in way that does not diminish the patient's experience.
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Support
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I don't hear anything. That sounds frightening, but please know you are safe here in the hospital.
Thanks. I know I have had issues in the past with hallucinations, but sometimes they feel so real.
Great job! This educational response casts doubt on the patient's delusion, and gives reassurance about the safety, and information about the therapeutic effects of his medication.
I don't see any evidence of that. Taking your medication may lower the frequency of voices you hear.
I guess that's true. Not everything these voices tell me is true and maybe the medication would help get rid of them.
What brings you in today?
Look. I'm not crazy, OK. I've got some problems, I know, but I'm not crazy. It's these voices I get. They're everywhere and everyone and they just kept getting louder. They kept getting harsher... just awful.
Do you ever hear things that others do not hear?
Yeah, it's bad. I hear voices, people I don't know talking to me from inside my head. I can hear them now too. I've been hearing them constantly.
I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in, let me learn more about what you're experiencing, and I will try to help.
I appreciate your sympathy.
Do you ever think people are trying to harm you?
They're looking for me, I know it. I don't see them, I don't know why, but I do know they're following me.
When did your symptoms start?
This week they've been loud, and harsh. They kept telling me to do things I didn't want to. I just wanted to make them stop so badly, it's scary when it's your own head, you know? I just wanted to make them stop... I got help before and the voices quieted down. But they got worse over this past week.
Did the hallucinations start gradually?
The voices got worse and worse over the last week, but they've been there for years.
Are your hallucinations constant?
Yes, constantly. I hear them constantly. It was getting worse this week, I couldn't even hear my own thoughts through it all. I told my mom it was bad again last night, and she brought me in.
Can you describe your hallucinations?
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How have you been sleeping?
Well, I've got insomnia, you know? So it's tough for me to even get sleep on normal night, but lately it's been getting worse. I'm a light sleeper so when I hear something or I'm having nightmares, I just wake right up. It's like zero to sixty, and I'm sitting there trying to fall back asleep for most of the night.
I'm sorry to hear that (No matching questions found.)
I'm sorry to hear that
Thank you so much. Feels good to hear a kind voice.
Do you have any thoughts about harming other people/ (Clarified to Have you ever thought about harming yourself or others?.)
Never about anyone else. The voices only want me to die. (Clarified to if I have ever had thoughts of harming myself or others.)
Do you take any medications for your insomnia?
Yeah, I take Trazodone just about every night before I sleep.
I'm sorry to hear that you haven't been sleeping well. Insomnia can take a toll on your mental and physical health, and can exacerbate stress. We will try to find a way to alleviate some of your insomnia symptoms so that you can get some rest.
Thank you. I appreciate your compassion.
Do you feel safe at Home?
No, I have to stay alert all the time, man, because they're out there. I can't let my guard down.
How has your appetite?
I don't really think of eating lately, I'm just not hungry. Got other things on my mind.
What other things are on your mind?
I'm just trying to get through college. Going for my Audio Engineering degree. I wanna make something of myself, man, so I gotta get through it.
Smoking can cause many negative health impacts including lung disease and cancers.
Huh. Thanks for the info.
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That sounds unsettling, I'm sorry you feel like there are people coming after you. Symptoms of schizophrenia can include paranoid thought process, so it is expected for you to feel this way. The medication we've given you should be able to decrease this feeling of paranoia that you're experiencing. in the meantime, i can assure you that you are safe here and and that our staff here at the hospital only wants to help you feel better.
I appreciate your sympathy.
Do you smoke tobacco?
Sure, I smoke cigarettes.
How many packs a day do you smoke?
Usually I go through about a pack a day, give or take.
Have you thought about quitting smoking?
Not anytime soon, no. Sometimes it helps still my mind some... I don't know how, it just does.
what do you do for a job?
I stock shelves at this local grocery store.
Do you feel safe at home?
No, I have to stay alert all the time, man, because they're out there. I can't let my guard down.
Smoking might offer you some temporary stress relief, but it has short-term and long-term negative effects on your health. In the short-term, smoking can affect your mental health and exacerbate your stress level. Long-term smoking puts you at risk for high blood pressure, heart disease, and lung disease. There are medications and nicotine replacement products that can help you stop smoking. I would like for you to consult with someone for help with smoking cessation. (No matching questions found.)
Smoking might offer you some temporary stress relief, but it has short-term and long-term negative effects on your health. In the short-term, smoking can affect your mental health and exacerbate your stress level. Long-term smoking puts you at risk for high blood pressure, heart disease, and lung disease. There are medications and nicotine replacement products that can help you stop smoking. I would like for you to consult with someone for help with smoking cessation.
Yeah, good call.
Do you ever see things that are not there?
No, I've got 20/20 vision, heh. It's what I hear that's the double trouble.
Do you taste things that are not there?
No, never.
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I don't have anxiety problems, but I do get scared sometimes. It's just whoever's been following me sets me on high alert sometimes.
Have you been diagnosed with bipolar disorder?
Nah, way different from my problem. Different diagnosis, different struggle.
At what age did you get Schizophrenia?
I've known about it for five years. I was 23 when I was diagnosed. Five years ago.
How often have you had trouble falling asleep/
Just about every night, I've got insomnia and the voices don't really help me sleep.
have you had trouble falling asleep before?
Yeah, I've got plenty of trouble with falling asleep, you know? It's hard for me to just let the thoughts in my head go because I've got these voices all over me every night.
Can you tell me more about your sleep?
Well, I've got insomnia, you know? So it's tough for me to even get sleep on normal night, but lately it's been getting worse. I'm a light sleeper so when I hear something or I'm having nightmares, I just wake right up. It's like zero to sixty, and I'm sitting there trying to fall back asleep for most of the night.
How many hours a night do you sleep?
I've been getting 2, maybe 3 hours a night.
How often do you wake up during the night?
A few times at least. Between nightmares and the voices, it's hard to get back to sleep after I'm up once.
How often do you wake up during the night?
A few times at least. Between nightmares and the voices, it's hard to get back to sleep after I'm up once.
Does anything make it harder to
I get nightmares every now and then... they don't help very much.
have you had to go to the hospital for a psychiatric disorder?
Yes, three times. Unless you're counting this time, then four. If not it's three for sure.
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Have you been hospitalized as an adult?
Yes, I was here three times because of my schizophrenia. When I was 23, 25, and 26.
What were you previously admitted to the hospital for?
I've only ever had to come here because of the voices, nothing else.
Can you tell me about your history of psychiatric treatment?
I've been in and out of psych wards about three times. First time was when I was 23, back when I started hearing the voices. They were pretty bad back then, man. Since then it's been ups and downs, you know? Came back in at 25 and 26 when the voices got too loud, even through the medication.
Can you tell me what the voices command you to do?
Well, they want me dead, you know? The voices were telling me chew up all the pills in our cabinets two days ago. I didn't. I don't want to die, you know? I've got people I love and that love me, and I've got a future. I just didn't want to take a chance, so I told my mom what they were saying and she brought me in.
Have you ever attempted suicide?
It got really bad once, a few years ago. I just wanted them to stop, just wanted it all to stop... I took a whole bottle of Tylenol and closed my eyes. Wasn't expecting to wake up at all, but I did. I only remember flashes of the ambulance and the ER. I do remember just crying my eyes out though like I couldn't believe it had come to that. I won't let it get there again, never again.
Have you ever wished that you were dead?
Yeah, I have. Back when the voices were always loud, I wished that I'd just die. It got pretty bad. I'm not gonna listen to them.
Have the voices ever told you to hurt someone?
No. Just myself.
Are you on any prescription medication?
I have schizophrenia medication and something for my insomnia. They help, when I have them.
Do you take a medication you can buy at the store?
No, I need stronger stuff for what I've got.
Do you take any herbal supplements?
Supplements? No, I don't.
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It usually works, it's good. Quiets down the voices, helps me keep things straight.
Have you been taking prescription sleep medication?
Yeah, I take Trazodone just about every night before I sleep.
How much is one dose of Trazodone?
I don't know, I just know I'm supposed to take Trazodone before I sleep.
How many times a day are you taking a dose of trazodone?
My Trazodone? It helps me sleep, so I pretty much take it every night.
what is the reason you take trazodone? (Clarified to For what health condition do you take trazodone?.)
It helps me get to sleep. (Clarified to why I am prescribed trazodone.)
Do you use drugs now?
I don't mess around with that.
Do you drink alcohol?
I have a beer once in awhile, yeah.
Do you have alcohol in your system?
No, of course not.
How much alcohol do you usually drink in one sitting?
Usually I have one beer, sometimes I'll have two. I never really drink more than that at once, I hate feeling drunk.
Do you binge drink?
Definitely not.
Do you use tobacco?
Sure, I smoke cigarettes.
How much do you smoke?
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Usually I go through about a pack a day, give or take.
When did you first try smoking?
I started when I was 16.
Do you plan to quit smoking?
Not anytime soon, no. Sometimes it helps still my mind some... I don't know how, it just does.
Do you have a job?
Yes, I have a job. I'm working at the local grocery, stocking shelves. They're flexible with my hours and they'll work around my bad days.
Is your job full time?
Part-time really, I'm trying to finish school at the same time so I can't really afford a nine to five yet. I get about 20 or 30 hours in a week, on a good week.
Are you in school?
Yeah, I went back to college. Going for my Bachelor's degree, trying to at least.
What degree are you seeking at school?
Audio Engineering. I figure, I'm a pretty good musician; not great, not terrible, but pretty good. Anyway, I don't know that I could make a sustainable living on playing music, so I'm learning the way it gets made. Like produced, you know? I really like it.
Who do you live with?
I live with my mom at her house.
Do you have children?
No, I don't have kids.
Are you married?
No, nothing like that. I've got a girlfriend, and we're pretty serious but I need to hold down a job before I can think about getting hitched.
good to hear about you and your girl friend
Thank you so much. Feels good to hear a kind voice.
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No, no fever.
Do you get chills?
No, I don't get chills.
Have you been having night sweats?
Nah.
How often have you felt fatigued?
I'm not tired. I've been dealing with the insomnia just as long as the voices. It's just been more difficult to sleep at all, lately.
Have you lost weight?
Yeah, I've lost a little bit of weight I guess.
Do you have a cough?
Nothing like that, no.
Do you have respiratory problems
No, I've got strong lungs, man.
Do normal activities make you short breath?
No, I can catch my breath, no problem.
Are you wheezing?
Wheezing? Nah, I breathe just fine.
Do you currently have abdominal pain?
My stomach is fine.
Have you had trouble swallowing?
No, I'm fine.
Are you feeling nauseated?
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No, nausea doesn't bother me.
Are you vomiting?
Nah, I haven't thrown up since high school I think.
Are you feeling constipated
Nah, man.
Have you had diarrhea lately?
No, I don't have problems with that.
How have your bowel movements been recently?
That's been the same, no change.
Do you feel weak
Not really, no.
Do you get headaches
The voices make it hard to think a lot, but it's different from a headache so no.
Do you have numbness anywhere
I don't feel numb. I haven't been feeling numb.
Have you been dizzy
Not unless I spin around, man.
How is your coordination
It's fine. I'm fine.
Do you have any concerns about your memory
My memory has been crystal clear.
Have you fallen recently?
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Do you have any family history of hallucination? (Clarified to Do you have a family history of hallucination?.)
No, I'm the only one in my family who has it. (Clarified to if I have a family history of hallucination.)
Can you tell me about your family history?
I don't know of any other problems in the family... my mom's pretty healthy. Not sure about my dad. As far as I know, I'm the only one with issues.
Do your family members have health problems?
I don't know of any other problems in the family... my mom's pretty healthy. Not sure about my dad. As far as I know, I'm the only one with issues.
Do you have family history of depression?
Not that I know about.
Do you have religious preference?
I go to church with my mom on Sundays. It's one of the things we do together. We're non- denominational.
Does your family support you?
I'm close with my mom. She's been letting me live with her while I finish up school. It's been good. It's nice to have someone to talk to when I need it.
It sounds like you have a healthy support system through your family and friends which is great. It sounds like you work hard to manage your time effectively, too, remember to take out time to relax or take a walk.
Thank you. I actually feel pretty safe here.
How often do you urinate?
About the same as always.
Assessed vitals
Auscultated breath sounds
Auscultated breath sounds
Auscultated heart sounds
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Auscultated breath sounds
Auscultated heart sounds
Auscultated breath sounds
Inspected interior of arms and wrists: no visible abnormalities
Inspected facial and oral movements: normal
Is there any self-harm you would like to tell me about?
I haven't hurt my body like that. They want me to hurt myself. They tell me to all the time. I try not to listen to them.
have you ever hurt yourself in order to cope with your feelings?
I've only tried to hurt myself once, and that was because the voices told me to. I haven't tried anything since then, and I've never hurt my body, never cut myself or anything like that. It would hurt too much.
How likely are you to intentionally hurt yourself?
I feel calmer now. I don't want to hurt myself.
Inspected upper extremities for involuntary movement: normal
Inspected upper extremities for involuntary movement: normal
Inspected lower extremities for involuntary movement: normal
Inspected torso for involuntary movement: normal
Assessed general appearance: clothing is disheveled, signs indicating lack of grooming or self-care
Assessed attitude: suspicious, guarded, or evasive
Assessed speech: expected rate of speech, appropriate volume, and no issues with articulation
Assessed mood and affect: stable mood, but affect is blunted or flat
Have you experienced any mood changes?
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Count backwards from 100 by 7 until you get to the 60s
100, 93, 86, uh... 79... (Mr. Ford finishes the sequence)
Assessed cognition
How are apples and oranges alike?
Uh, they both grow on trees.
How are a lake and an ocean alike?
You can swim in both of them.
How are a trumpet and a flute alike?
You have to blow into both of them.
Assessed cognition
Assessed cognition
Repeat and remember burger, tulip, nose and tea
Burger, tulip, nose and tea.
How did you celebrate your last birthday?
I went to a concert with some friends.
Repeat the four words from before
Burger, tulip, nose, and tea.
Copy the shapes exactly as you see them
OK...
Assessed insight: demonstrates awareness of illness and willingness to seek treatment
Assessed judgment: demonstrates good judgment
What would you do if you found a stamped envelope on the sidewalk?
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I would put it in the mail box.
Auscultated breath sounds
Auscultated breath sounds
Auscultated heart sounds
Inspected interior of arms and wrists: no visible abnormalities
Inspected facial and oral movements: normal
Inspected upper extremities for involuntary movement: normal
Inspected lower extremities for involuntary movement: normal
Assessed general appearance: clothing is disheveled, signs indicating lack of grooming or self-care
Do you ever think people are trying to harm you?
They're looking for me, I know it. I don't see them, I don't know why, but I do know they're following me.
When did your symptoms start?
This week they've been loud, and harsh. They kept telling me to do things I didn't want to. I just wanted to make them stop so badly, it's scary when it's your own head, you know? I just wanted to make them stop... I got help before and the voices quieted down. But they got worse over this past week.
Did the hallucinations start gradually?
The voices got worse and worse over the last week, but they've been there for years.
Are your hallucinations constant?
Yes, constantly. I hear them constantly. It was getting worse this week, I couldn't even hear my own thoughts through it all. I told my mom it was bad again last night, and she brought me in.
Can you describe your hallucinations?
They're different every time. Male voices, female voices... Sometimes just one but it could be a choir. They know how to get a rise from me, or how to get surprise from me. They get under my skin, you know? They tell me to do things. Sometimes on a whim or sometimes they shout it at me all night.
Do the voices tell you to do anything?
Focused Exam Schizophrenia Completed Shadow Health Eric Ford Transcript
Course: Concepts of Nursing III (BSN 346)
University: Nightingale College
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