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Exam (elaborations)

SHADOW HEALTH Mental Health Student Handbook | MENTAL HEALTH

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This assignment provides the opportunity to conduct a focused exam on a patient presenting with schizophrenia. You will assess relevant body systems to evaluate physiological symptoms. You will also interview the patient, including an involuntary movement evaluation, conduct a mental status exam, and provide therapeutic communication. After the patient exam, you will complete an SBAR hand-off. On average, this assignment should take 90 minutes to complete. This assignment includes subjective data collection around sensitive topics such as suicidal ideation and schizophrenic hallucination. Instructions: Perform a focused examination of an adult male patient who has been experiencing auditory hallucinations and paranoid thoughts. Gather the information needed to assess the situation and transfer care to Preceptor Diana. Plan your time: Assignment First Turn In Allow Reopening Flexible Turn In Time Estimate ~90 minutes ~110 minutes ~160 minutes Patient Examination • Review the orders and patient data in the EHR • Interview and examine Eric Ford to gather subjective and objective patient data • Gather HPI and health history, including Mr. Ford’s psychiatric history • Use the Question tab in this Communication Box to gather subjective data from Mr. Ford • Use the Educate tab in the Communication Box to inform and educate Mr. Ford on relevant topics revealed in subjective data collection • Use the Empathize tab in the Communication Box to practice therapeutic communication when opportunities arise during the interview • Maintain respect for the patient’s dignity while broaching sensitive subjects • Conduct the relevant tests to evaluate the patient’s symptoms • Conduct a mental status exam to determine the patient’s mental health and risk factors • Document the findings of the physical examination in the Objective Data Collection tab in the EHR • Document subjective data, using professional terminology, in the Nursing Admitting Note tab in the EHR Patient Hand-Off: • Determine when enough information has been gathered to transfer care to Preceptor Diana • Communicate the patient’s Situation, Background, your Assessment, and your Recommendation in an SBAR hand-off to your preceptor

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Written in
2021/2022
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