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NURS 6512 Week 6 Shadow Health Mental Health Physical Assessment SUBJECTIVE ~WaldeN University~ Shadow Health

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NURS 6512 Week 6 Shadow Health Mental Health Physical Assessment SUBJECTIVE ~WaldeN University~ Shadow Health

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6/6/2018 Mental Health | Completed | Shadow Health


Mental Health Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment




Your Results Lab Pass




Overview
Subjective Data Collection: 43 of 44 (97.7%)
Transcript

Subjective Data Collection Hover To Reveal...
Indicates an item that you found.
Hover over the Patient Data items
Objective Data Collection Indicates an item that is available to be
below to reveal important information,
found.
including Pro Tips and Example
Education & Empathy
Questions.
Documentation

Lifespan
Category Scored Items Patient Data
Review Questions Not Scored
Experts selected these topics as essential
Self-Reflection A combination of open and closed questions
components of a strong, thorough
will yield better patient data. The following
interview with this patient.
details are facts of the patient's case.



Chief Complaint


Established chief complaint Reports difficulty sleeping and
"feeling nervous"
Reports seeking treatment because she
has an upcoming exam and feels "too
foggy to study"
Reports excessive worry and "racing
thoughts" before bed




History of Present Illness


Asked about onset and duration Reports difficulty sleeping began 3 1/2
of symptoms weeks ago
Reports sleep difficulties have been
occurring regularly during past 3 1/2 weeks




https://chamberlain.shadowhealth.com/assignment_attempts/3558473 1/7

, 6/6/2018 Mental Health | Completed | Shadow Health



Asked about frequency of symptoms Reports difficulty sleeping at least four or
five times a week




Asked about aggravating factors Reports sleeping becomes more difficult
when she can not redirect her thoughts
from the things she is worried about
Denies naps during the day
Reports drinking caffeine to stay alert
Reports stopping caffeine use after 4
P.M. Denies alcohol use before bed
Denies drug use before bed
Reports respiratory problems are
controlled and not interfering with sleep




Asked about relieving factors Reports sleeping more easily if she
can distract herself from her "racing
thoughts"
Reports no exercise




Asked about impact of Reports feeling tired and "out of it" most
sleeping problems on daily living
of the time during the day due to lack of
sleep
Reports no increased chance of drifting
off during the day despite lack of sleep




Followed up about patient's Reports feeling slowed down and tired,
experience feeling "out of it"
having trouble focusing, and generally
feeling "less sharp"




Asked about anxiety symptoms Reports feelings of anxiety as "thoughts
she can't turn off" and "being on edge"
Reports worry about the future, but no
sense of impending doom
Reports no panic attacks
Reports difficulty concentrating due to
fatigue from lack of sleep
Reports only restlessness occurs just
before bed
Reports slight irritability due to fatigue




Asked about impact of anxiety on Reports stress only interferes with daily
daily living
life because it interrupts her sleep
Reports stress does not prevent her from
completing her usual activities




Asked about sleep quality Reports falling asleep often takes


https://chamberlain.shadowhealth.com/assignment_attempts/3558473 2/7

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