Shadow Health Focused Exam: Rachel Adler – ETOH | Exams Nursing | Docsity (2024)

Download Shadow Health Focused Exam: Rachel Adler – ETOH and more Exams Nursing in PDF only on Docsity! Shadow Health Focused Exam: Rachel Adler – ETOH Shadow Health Focused Exam: Rachel Adler – ETOH Chief Complaint Finding: Established chief complaint and reason for admittance Finding: Reports car accident Example Question: Why were you admitted? Finding: Reports injury Example Question: What caused your injury? Finding: Reports passive suicidal ideation Example Question: What brings you in today? History of Present Illness Finding: Followed up on details of car accident Finding: Example Question: Did you lose consciousness during the car accident? Finding: Reports being unsure of how the accident happened Example Question: Do you know what caused the car accident? Finding: Reports wearing seatbelt Example Finding: Reports since accident, not sure what to think about what she did Example Question: How do you feel since the accident? Finding: Asked about onset and duration of pain Finding: Reports pain started immediately after accident Example Question: When did you last experience the pain? Finding: Reports accident was last night Example Question: When did the car accident happen? Finding: Reports accident was at 10 pm Example Question: When did the car accident happen? Finding: Asked about location of pain Finding: Reports pain is in right wrist Example Question: Does your wrist hurt? Finding: Asked about aggravating factors of pain Finding: Reports increased pain when bending or twisting (R) wrist Example Question: Is your pain worse with movement? Finding: Reports increased pain when trying to lift items, even small ones such as a hairbrush Example Question: Is your pain worse with movement? Finding: Asked about treatment and relieving factors of pain Finding: Reports rest improves pain Example Question: Does lying down help your pain? Finding: Reports ibuprofen has significantly reduced pain Example Question: Has ibuprofen helped your pain? Finding: Reports wearing sling helps Example Question: Has wearing the sling helped your pain? Finding: Asked about characteristics of pain Finding: Reports pain is aching Example Question: Is the pain aching? Finding: Denies sharp or shooting pain Example Question: Do you have shooting pain? Finding: Asked about severity of pain Finding: Reports current pain level is 2/10 Example Question: How would you rate your pain? Finding: Reports pain without medication was 8/10 Example Question: How would you rate your pain without medication? Past Medical History Finding: Asked about existing health conditions Finding: Reports no known health problems Example Question: What health problems do you have? Finding: Asked about history of mental health Finding: Denies previous history of mental illness diagnoses Example Question: Do you have a history of psychiatric illness? Finding: Denies past depression Example Question: Have you experienced any depression or sadness? Finding: Reports feeling anxious over the past six months - has not sought treatment/counseling Example Question: Have you felt anxious? Finding: Reports can not deal with stress of school and life in general Example Question: Is your life stressful? Finding: Reports that she does not care what happens to her anymore (passive suicidal ideation) Example Question: How do you cope with stress? Finding: Followed up on stress issues Finding: Reports stress over parental relationships Example Question: How do you get along with your parents? Finding: Reports stress over school Example Question: Can you tell me about school? Finding: Reports stress over grades Example Question: How are your grades? Finding: Followed up on self harm Finding: Reports no active suicidal thoughts prior to accident Example Question: Do you think about ending your life? Finding: Denies past suicide attempts Example Question: Have you ever attempted suicide? Finding: Followed up on confusion about life/death Finding: Reports feeling it may be better if she "does not have to put up with the stress of life anymore" Example Question: Why do you think life is not worth living? Finding: Reports not caring that she put herself at risk for injury/death by drinking and driving Example Question: Why do you think life is not worth living? Finding: Reports feeling like it would be better if she had died in car accident Example Question: Why do you think life is not worth living? Finding: Denies ibuprofen side effects Example Question: Have you experienced side effects from ibuprofen? Finding: Followed up on oral contraceptive Finding: Reports taking Ortho Tri- Cyclen Lo Example Question: What birth control pills are you taking? Finding: Reports Ortho Tri-Cyclen Lo frequency: 1 pill per day Example Question: When do you take your birth control? Finding: Denies skipping pills Example Question: Have you missed any doses of your birth control pill? Finding: Reports taking pill in the morning Example Question: When do you take your birth control? Finding: Denies Ortho Tri-Cyclen Lo side effects Example Question: Are you having any side effects from your birth control? Family History Finding: Asked about relevant family history Finding: Reports mother has anxiety disorder Example Question: Does your mother have health problems? Finding: Reports father has no major medical issues Example Question: Does your father have any health issues? Finding: Reports maternal grandfather had a history of alcoholism Example Question: Has anyone in your family had a serious illness? Social History Finding: Asked about education Finding: Currently a college student Example Question: Can you tell me about school? Finding: Is a junior Example Question: What year are you in college? Finding: Reports being a good student Example Question: Are you a good student? Finding: Reports majoring in physics Example Question: What degree are you getting? Finding: Asked about work Finding: Denies having a job outside of school Example Question: Do you work and go to school? Finding: Asked about family and support system Finding: Describes relationship with parents as "decent" Tell me about your parents. Finding: Reports arguing with her mother more frequently as of late Example Question: What is your relationship with your mother like? Finding: Reports mother is very judgemental and has high expectations Example Question: What is your relationship with your mother like? Finding: Reports interacts minimally with mother and turns to father for support Example Question: Tell me about your parents. Finding: Reports has one sibling (brother) who lives out of state - see him on holidays Example Question: Tell me about your brother. Finding: Reports feeling like she has few close friends at school Example Question: Do you have friends at school? Finding: Asked about living situation Finding: Reports living in a dorm Example Question: Where do you live? Finding: Reports living with one roommate Example Question: Do you have a roommate? Finding: Asked about exercise Finding: Reports exercising 3 - 4 days a week Example Question: How much do you exercise? Finding: Prefers running Example Question: What kind of exercise do you do? Finding: Occasionally goes to the gym to workout Example Question: What kind of exercise do you do? Finding: Asked about diet Finding: Reports typically skipping breakfast Example Question: What do you eat for breakfast? Finding: Reports fruit or salad for typical lunch Example Question: What do you eat for lunch? Finding: Reports a small dinner, typically a sandwich Example Question: What do you eat for dinner? Finding: Asked about appetite Finding: Reports loss of appetite Example Question: How is your appetite? Finding: Reports feeling hungover most of the time when she drinks Example Question: How often do you get hangovers? CAGE Assessment Finding: Asked about cutting down on drinking Finding: Reports that she has not tried to cut down on drinking Example Question: Have you tried to cut back on drinking? Finding: Reports when she drinks she tends to eat less Example Question: Does alcohol affect your appetite? Finding: Asked about others perceptions of drinking Finding: Reports that since she mostly drinks with friends, no one cares about her drinking Example Question: What do your friends think about your drinking? Finding: Reports that she rarely drinks in front of parents - so they do not know how much she drinks Example Question: What do your parents think about your drinking? Finding: Asked about feelings around drinking Finding: Reports that she drinks to feel better or to feel nothing Example Question: Why do you drink? Finding: Reports her drinking does not hurt anyone, so she does not feel bad or guilty for drinking Example Question: Do you ever feel guilty about drinking? Finding: Asked about drinking first thing in the morning Finding: Denies drinking first thing in the morning Example Question: Do you drink alcohol first thing in the morning? Review of Systems Finding: Asked about general symptoms Finding: Denies fever Example Question: Are you having fevers? Finding: Denies chills Have you had any chills? Finding: Denies night sweats Example Question: Do you have night sweats? Finding: Reports occasional fatigue Example Question: Have you felt fatigued? Finding: Asked about review of systems for HEENT Finding: Denies impaired vision Example Question: How are your eyes? Finding: Denies impaired hearing Example Question: How is your hearing? Finding: Asked about review of systems for respiratory Finding: Denies cough Example Question: Do you have a cough? Finding: Denies shortness of breath Example Question: Is it hard for you to breathe when you exercise? Finding: Denies dyspnea on exertion Example Question: Is your breathing okay when you walk? Finding: Denies wheezing Example Question: Are you wheezing? Finding: Asked about review of systems for cardiovascular Finding: Do you have any abdominal pain? Finding: Reports no nausea Example Question: Have you been nauseous? Finding: Denies difficulty swallowing Example Question: Do you have difficulty swallowing? Finding: Denies vomiting Example Question: Have you been vomiting? Finding: Denies constipation Example Question: Are you constipated? Finding: Denies diarrhea Example Question: Has your stool changed? Finding: Denies changes in stool or bowel patterns Example Question: Are your bowel movements normal? Finding: Asked about review of systems for musculoskeletal Finding: Reports recent injury - sprained (R) wrist Example Question: Do you have any joint problems? Finding: Denies joint pain Example Question: Do you have any joint problems? Finding: Denies erythema Example Question: Has your skin been red? Finding: Denies edema of joints prior to wrist injury Example Question: Have your joints been swollen? Finding: Asked about review of systems for neurological Finding: Denies weakness Example Question: Do you feel weak? Finding: Denies frequent headaches Example Question: Do you get frequent headaches? Finding: Reports slight tingling in fingers on right hand Example Question: Do you feel any numbness or tingling anywhere? Finding: Denies syncope, dizziness, fainting, or vertigo Example Ques. tion: Have you felt dizzy? Finding: Denies changes in coordination Example Question: How is your coordination? Finding: Denies changes in memory Example Question: How has your memory been? Finding: Denies recent falls SBAR S Rachel Adler is a 20-year-old White woman admitted from the ER last night after a MVA related to alcohol use. She sustained a (R) wrist sprain during the accident and voiced a lack of concern for her personal safety, which is why they admitted her to the psych unit. B Ms. Adler has a history of alcohol use, but no previous overt suicidal attempts. She reports a great deal of stress related to college, her relationship with her mother, and self-esteem issues surrounding academic performance. After her accident last evening she stated she did not care what happened to her. Based on her reckless behavior and intoxication she was admitted for treatment of ETOH use and suicidal ideation A Ms. Adler had a pain report of 8/10 of her (R) wrist. She experienced relief with ibuprofen while in the ER and after being medicated she rates her pain as 2/10. She gets anxious when questioned about her alcohol use and her ability to stay safe. Other than the wrist sprain, she is in good general health. She does have a peanut allergy, but no medication allergies. R Based on my assessment, we need to follow up today with completing an assessment for suicidal ideation and make sure she is on the roster for q 15 min