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PTSD mental status note

exam help practice
Course

Mental Health Nurs (NURS 4163)

54 Documents
Students shared 54 documents in this course
Academic year: 2020/2021
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Prairie View A&M University

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2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health

app.shadowhealth/assignment_attempts/6136778 1/

Focused Exam: PTSD (Part 2 of 2)

Mental Health Nursing Theory/Practicum - Spring 2020, NURS 4163/

Return to Assignment (/assignments/291252/)

Reflections

Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the page.

Documentation Review

Mental Status Note

Student Response Model Documentation

Appearance Portrays tension and bent posture Ms. Diaz is a 48-year-old Cuban American woman of aver height. She appears overweight. Eye contact is direct. He expression is tense and posture rigid, with a clenched jaw and clenched fists. Her clothing is appropriate to her age occasion. She appears well-groomed.

Attitude Suspicious, guarded, evasive Ms. Diaz is cooperative, but is anxious and appears guard when asked about her social history.

Speech WNL Ms. Diaz's speech is normal for her age, education, and general ability. No observed problems with liveliness, volu intensity, or flow.

Mood and Affect When PTSD is bad - mood is unstable Easier for pt to get angry over simple things Pt reports "If someone says something ignorant or hurtful, I think about it all day. I can't let it go. I lay awake chewing it over, getting angrier and angrier. Sometimes I'll swing from fear to anger so quickly."

Ms. Diaz is guarded and appears to be moderately anxiou Her affect is appropriate to the situation but constricted. S appears stable. She is aware that she is anxious and tens

Thought Process WNL Ms. Diaz's thoughts appear coherent, logical, and relevan Observed no sign of potential disordered behaviors. Observed no rhyming, clang association, or puns.

Nursing Admitting...

Mental Status Note

SBAR

2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health

app.shadowhealth/assignment_attempts/6136778 2/

Student Response Model Documentation

Thought Content WNL Ms. Diaz has some passive suicidal ideation, reporting tha she is not sure she can go on like this anymore because o her exhaustion and tension from PTSD. She appears paranoid, stating that she checks her doors and windows multiple times before she goes to sleep at night. She cann sleep deeply because of her paranoia and fears.

Perceptual Disturbances

Reports having suicidal thoughts for years (near time of assualt) Pt reports depression, anxiety, and exhaustion taking over their life. Feels hopeless

Ms. Diaz has no delusions or hallucinations. There are no observable abnormal tendencies.

Orientation and Level of Consciousness

Alert and oriented x4 (person, place, time, situation) A&O x 4

Cognition WNL No problems with serial 7s or abstract reasoning. Ms. Dia memory appears normal and she is attentive and aware o situation.

Insight WNL - demonstrates awareness of illness and willingness to seek treatment

Ms. Diaz is aware that her symptoms stem from her PTSD She knows that her anxiety, depression, and disordered s stem from her past trauma.

Judgment WNL - demonstrates good judgement Ms. Diaz does not connect smoking and lack of exercise t her difficulty sleeping. She knows that smoking is bad but not actively taking steps to quit. However, her response to "stamped envelope" scenario shows that she is capable o good judgment.

Discuss some strengths you felt you displayed during your interview.

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PTSD mental status note

Course: Mental Health Nurs (NURS 4163)

54 Documents
Students shared 54 documents in this course

University: Prairie View A&M University

Was this document helpful?
2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6136778 1/3
Focused Exam: PTSD (Part 2 of 2)
Mental Health Nursing Theory/Practicum - Spring 2020, NURS 4163/4262
Return to Assignment (/assignments/291252/)
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the
page.
Documentation Review
Mental Status Note
Student Response Model Documentation
Appearance Portrays tension and bent posture Ms. Diaz is a 48-year-old Cuban American woman of aver
height. She appears overweight. Eye contact is direct. He
expression is tense and posture rigid, with a clenched jaw
and clenched fists. Her clothing is appropriate to her age
occasion. She appears well-groomed.
Attitude Suspicious, guarded, evasive Ms. Diaz is cooperative, but is anxious and appears guard
when asked about her social history.
Speech WNL Ms. Diaz's speech is normal for her age, education, and
general ability. No observed problems with liveliness, volu
intensity, or flow.
Mood and Affect When PTSD is bad - mood is unstable
Easier for pt to get angry over simple things
Pt reports "If someone says something ignorant or hurtful, I
think about it all day. I can't let it go. I lay awake chewing it
over, getting angrier and angrier. Sometimes I'll swing from
fear to anger so quickly."
Ms. Diaz is guarded and appears to be moderately anxiou
Her affect is appropriate to the situation but constricted. S
appears stable. She is aware that she is anxious and tens
Thought Process WNL Ms. Diaz's thoughts appear coherent, logical, and relevan
Observed no sign of potential disordered behaviors.
Observed no rhyming, clang association, or puns.
Nursing Admitting...
Mental Status Note
SBAR

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