2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health
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 proce
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
Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
SBAR
Chief Complaint Patient reports "I haven't been able to get a good night of Ms. Diaz presented at the clinic with severe sleep issues
sleep in weeks. I am having trouble falling asleep, and I only she said were impacting her life. She claimed she was un
get a few hours of sleep at a time ... I wake up several times to rest and was suffering from insomnia, nightmares, and
during the night, and I can't seem to let myself relax. My frequent waking.
nightmares are getting worse, and I am starting to feel really
frayed around the edges. I need help."
History of Present Sleep habits: Pt reports not actually falling asleep until 2/3 am Nicole is a 48 year-old Cuban American woman with a his
Illness and gets in bed around midnight. Pt reports refraining from of hypertension and post-traumatic stress disorder.
using screens before bed and it hasn't made a difference. Pt
reports checking doors and windows a few times before
going to bed and still feels anxious to go to sleep
nonetheless. Pt reports getting between 4-5 hrs of sleep a
night.
Allergies NKA NKA
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 proce
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
Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
SBAR
Chief Complaint Patient reports "I haven't been able to get a good night of Ms. Diaz presented at the clinic with severe sleep issues
sleep in weeks. I am having trouble falling asleep, and I only she said were impacting her life. She claimed she was un
get a few hours of sleep at a time ... I wake up several times to rest and was suffering from insomnia, nightmares, and
during the night, and I can't seem to let myself relax. My frequent waking.
nightmares are getting worse, and I am starting to feel really
frayed around the edges. I need help."
History of Present Sleep habits: Pt reports not actually falling asleep until 2/3 am Nicole is a 48 year-old Cuban American woman with a his
Illness and gets in bed around midnight. Pt reports refraining from of hypertension and post-traumatic stress disorder.
using screens before bed and it hasn't made a difference. Pt
reports checking doors and windows a few times before
going to bed and still feels anxious to go to sleep
nonetheless. Pt reports getting between 4-5 hrs of sleep a
night.
Allergies NKA NKA
https://app.shadowhealth.com/assignment_attempts/6136778 1/3
