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PTSD SBAR - exam help practice
Mental Health Nurs (NURS 4163)
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
SBAR
Student Response Model Documentation
1. Situation Ms. Diaz is a 48 year old female who came in because she hasn't been able to get a good nights sleep in weeks. She reports having only gotten between 4 and 5 hours of sleep a night. She reports her nightmares are getting worse and keep her up at night.
Ms. Diaz is a 48-year-old Cuban American woman who is to establish care at our clinic.
2. Background Ms. Diaz reports being diagnosed with PTSD as a result of a sexual assualt she experienced about 20 years ago.
Ms. Diaz has a history of hypertension and PTSD. She is overweight, having gained 20 pounds over the past two ye She has difficulty sleeping due to anxiety and nightmares. has suicidal thoughts at times but has never tried to take life. She is not having suicidal thoughts currently.
3. Assessment Ms. Diaz reports being extremely depressed, anxious, and exhausted. She reports having suicidal ideation for years since her attack due to her anxiety and exhaustion. She displays a change in thought content as a result of her PTSD. She reports being scared easily and constantly being on edge. She is alert and oriented x4 (person, place, time, situation). Everything else presented to be within normal limits. She currently takes lorazepam for her hypternsion, buspirone for her anxiety and buproprion for her depression. She reports having no known allergies.
Ms. Diaz' blood pressure is elevated (142/90); she did take losartan 100 mg this morning. Her weight is 181 (BMI 31. She does not exercise as much as before and eats most o her meals as carry-out. She continues to struggle with anxiety, depressed mood, and sleep disturbance due to nightmares. She takes bupropion 150 mg b.i. and buspi 15 mg b.i. for mood and anxiety as prescribed.
4. Recommendation I recommend further interviewing the patient about her suicidal ideations and coping strategies.
Based on my assessment, I recommend:
- A referral to the clinic mental health provider to address PTSD and stress management. Addressing those may hel improve sleep and depressed mood.
- I recommend a low fat, low salt diet, low sugar diet to manage weight, glucose, and blood pressure. A referral to clinic dietician will help to formulate a diet.
Nursing Admitting...
Mental Status Note
SBAR
Discuss some strengths you felt you displayed during your interview.
2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health
app.shadowhealth/assignment_attempts/6136778 2/
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PTSD SBAR - exam help practice
Course: Mental Health Nurs (NURS 4163)
University: Prairie View A&M University
