Dallas County Community College - RNSG 1443 Randy Adams documentation / Mental Health Case: Randy Adams Documentation Assignments (answered)2022 update

Mental Health Case: Randy Adams Documentation Assignments 1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder. Mr. Adams presents with headache and sensitivity to light and noise. His memory has also been impaired, demonstrated by his ability to recall two of the three words he was asked to remember. He states that his sleeping has been getting better. 2. Identify and document key nursing diagnoses for Mr. Adams. - Disturbed senesoy perception related to head injury as evidenced by sensitivity to light and noise - Ineffective coping related to traumatic event as evidenced by client stating he “tries not to think about the accident” - Anxiety related to traumatic event as evidenced by client exhibit restless behavior, appearing tense and asking to stand during assessment 3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care. Feedback Log 0:00 Patient 0:00 You checked scene safety. It was correct to check scene safety in order to maintain your own safety. 0:06 You introduced yourself. 0:37 You asked the patient: Is it OK for your wife to be here, while we talk? It was correct to let the patient give his consent for letting his wife be a part of the interview. 0:49 The patient said: I'm not sure what I would do without Joy.nYou answered: It sounds like your relationship with your wife is very important to you. nYou used the therapeutic technique of encouraging expression. 0:50 You washed your hands. 0:57 You identified the patient. From vSim for Nursing | Mental Health.