Psychiatric Mental Health Nur sing - Spring 2019, NURS 3360
Return to Assignment
Your Results
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
ReflectionsIndicates an item that you found.
Indicates an item that is available to be
found.
Category Scored Items
Experts selected these topics as essentialcomponents of a strong, thorough interviewwith this patient.Patient Data
Not Scored
A combination of open and closed questions
will yield better patien t data. The following
details are facts of the patient's case.
Chief Complaint
Established ch ief complaint Reports feeling excessively weak
Reports fatigue and sleepiness
History of Present Illness
Asked about onset and duration of
symptomsReports symptoms have been happening
for past month
Reports symptoms have been increasing
in the past week
Reports unable to get out of bed every
morning
Asked about frequency, duration, and
timing of symptomsReports feeling fatigued every morning
Reports feeling slight ly more energetic in
the afternoonSubjective Data Collect ion: 41 of 41 (100.0%)
© Shadow Health 2018®Focused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
1 of 6 3/3/2019, 5:58 PM Asked about aggravating factors of symptoms Reports feeling is worse in the morning
Reports no known triggers
Asked about treatment and relieving factors of
symptomsReports that lying down feels best when fatigued
Depression Screening
Asked about pleasure and interest in typical activities Reports loss of interest in typical activities
Reports not taking pleasure in things that typically would
Asked about feelings of depression Denies sadness or depression
Denies feeling hopeless
Asked about sleep Reports light sleep
Reports insomnia
Reports trouble falling asleep
Reports trouble staying asleep
Followed up on frequency of low energy Reports feeling low energy nearly every day
Asked about appetite and eating Reports loss of appetite
Denies overeating
Asked about self-concept Reports feeling bad about herself
Reports feeling guilty
Reports feeling embarrassed
Asked about changes in concentration Reports trouble concentrating
Asked about changes in speed with moving or
speakingDenies speaking too slowly
Denies speaking too quickly
Denies moving too slowly
Denies moving too quickly
Asked about suicidal ideation and self-harm Reports "it would be ok if I didn't wake up"
Denies wanting to hurt herself
Denies history of suicide attempts
Past Medical History
Asked about existing health conditions Reports hypothyroidismFocused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
2 of 6 3/3/2019, 5:58 PM Reports type 2 diabetes
Followed up on history of mental health Reports depression diagnosis
Denies past psychiatric admissions
Asked about allergies Denies general allergies
Denies environmental allergies
Denies latex allergy
Denies food allergies
Asked specifically abou t medication allergies Denies medicat ion allergies
Home Medications
Asked about home medications Reports medications for diabetes
Reports medications for depression
Reports medications for sleep
Reports medication for thyroid
Denies taking vitamins
Denies taking herbal supplements
Asked about medication regimen adherence Reports using a pillbox to organize me dications
Reports that her son helps her remember medications
Denies missing doses of medication
Denies missing doses of medication because of side
effects
Denies difficulty obtaining medications because of
finances
Denies difficulty obtaining medications because of
transportation
Followed up on last dose of home medications Reports receivin g insulin injection this morning
Reports taking medication for thyroid this morning
Denies taking any other medications today
Reports taking all medications as prescribed yesterday
Followed up on medications for diabetes Reports taking two types of insulin
Reports both insulin types are subcutaneous
Reports taking one form of insulin at mealtimes
Reports taking another form once a day
Reports that her son administers insulin injections
Denies remembering the specific types of insulin she
takes
Denies remembering the dose or units of insulin
Followed up on medication for sleep Denies remembering name of sleep medication
Denies knowing dosage of sleep medicationFocused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
3 of 6 3/3/2019, 5:58 PM
Return to Assignment
Your Results
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
ReflectionsIndicates an item that you found.
Indicates an item that is available to be
found.
Category Scored Items
Experts selected these topics as essentialcomponents of a strong, thorough interviewwith this patient.Patient Data
Not Scored
A combination of open and closed questions
will yield better patien t data. The following
details are facts of the patient's case.
Chief Complaint
Established ch ief complaint Reports feeling excessively weak
Reports fatigue and sleepiness
History of Present Illness
Asked about onset and duration of
symptomsReports symptoms have been happening
for past month
Reports symptoms have been increasing
in the past week
Reports unable to get out of bed every
morning
Asked about frequency, duration, and
timing of symptomsReports feeling fatigued every morning
Reports feeling slight ly more energetic in
the afternoonSubjective Data Collect ion: 41 of 41 (100.0%)
© Shadow Health 2018®Focused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
1 of 6 3/3/2019, 5:58 PM Asked about aggravating factors of symptoms Reports feeling is worse in the morning
Reports no known triggers
Asked about treatment and relieving factors of
symptomsReports that lying down feels best when fatigued
Depression Screening
Asked about pleasure and interest in typical activities Reports loss of interest in typical activities
Reports not taking pleasure in things that typically would
Asked about feelings of depression Denies sadness or depression
Denies feeling hopeless
Asked about sleep Reports light sleep
Reports insomnia
Reports trouble falling asleep
Reports trouble staying asleep
Followed up on frequency of low energy Reports feeling low energy nearly every day
Asked about appetite and eating Reports loss of appetite
Denies overeating
Asked about self-concept Reports feeling bad about herself
Reports feeling guilty
Reports feeling embarrassed
Asked about changes in concentration Reports trouble concentrating
Asked about changes in speed with moving or
speakingDenies speaking too slowly
Denies speaking too quickly
Denies moving too slowly
Denies moving too quickly
Asked about suicidal ideation and self-harm Reports "it would be ok if I didn't wake up"
Denies wanting to hurt herself
Denies history of suicide attempts
Past Medical History
Asked about existing health conditions Reports hypothyroidismFocused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
2 of 6 3/3/2019, 5:58 PM Reports type 2 diabetes
Followed up on history of mental health Reports depression diagnosis
Denies past psychiatric admissions
Asked about allergies Denies general allergies
Denies environmental allergies
Denies latex allergy
Denies food allergies
Asked specifically abou t medication allergies Denies medicat ion allergies
Home Medications
Asked about home medications Reports medications for diabetes
Reports medications for depression
Reports medications for sleep
Reports medication for thyroid
Denies taking vitamins
Denies taking herbal supplements
Asked about medication regimen adherence Reports using a pillbox to organize me dications
Reports that her son helps her remember medications
Denies missing doses of medication
Denies missing doses of medication because of side
effects
Denies difficulty obtaining medications because of
finances
Denies difficulty obtaining medications because of
transportation
Followed up on last dose of home medications Reports receivin g insulin injection this morning
Reports taking medication for thyroid this morning
Denies taking any other medications today
Reports taking all medications as prescribed yesterday
Followed up on medications for diabetes Reports taking two types of insulin
Reports both insulin types are subcutaneous
Reports taking one form of insulin at mealtimes
Reports taking another form once a day
Reports that her son administers insulin injections
Denies remembering the specific types of insulin she
takes
Denies remembering the dose or units of insulin
Followed up on medication for sleep Denies remembering name of sleep medication
Denies knowing dosage of sleep medicationFocused Exam: Depression | Comple ted | Shadow Health https://app .shadowhealth.com/assignment_attempts/4558614
3 of 6 3/3/2019, 5:58 PM
