Focused Exam: Alcohol Abuse (Part 3 of 3)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
Documentation
... [Show More] Review
Nursing Admitting... Mental Status Note SBAR
Nursing Admitting Note
Student Response Model Documentation
Chief Complaint right wirst pain following a car accident Ms. Adler has a sprained (R) wrist due to an
MVA caused by impaired driving. She is a self- harm risk and expressed passive suicidal ideation.
History of Present Illness
involved in a car accident while under the influence of alcohol, resulted in right wrist sprain
Rachel Adler is a 20-year-old White woman with a history of alcohol abuse and anxiety. She was brought to the ER last night by law enforcement after a MVA in which she was noted to be under the influence of alcohol and had an injured her
(R) wrist. Assessment in the ER confirmed a sprain of the (R) wrist, and an alcohol level of 0.2% (over the legal limit in the state for individuals under the age of 21) was determined at the scene. Ms. Adler stated she did not know what happened, but was told she received a ticket for DUI. Reported pain level upon arrival to the ER to be 8/10. Pain relief noted when ibuprofen administered. Ms. Adler denies any nausea, vomiting. Admitted to adult mental health unit based on positive assessment for self harm.
https://www.coursehero.com/file/38097455/Focused-Exam-Alcohol-Abuse-In-Progress-Attempt-Shadow-Health-reflectionspdf/
This study source was downloaded by 100000853289455 from CourseHero.com on 10-11-2023 05:28:47 GMT -05:00
https://wgu.shadowhealth.com/assignment_attempts/3763883 1/4
Student Response Model Documentation
Allergies peanuts Peanuts, reaction is itchy mouth and throat NKDA
Past Medical History
none, alcohol abuse associated with overwhelming stress
No medical issues
Denies use of prescription or recreational drugs, denies tobacco use
Past Surgical History
none No past surgical procedures
Medication History
ibuprofen prn, ortho tri-cyclen lo for birth control Ortho Tri Cyclen Lo, 1 tablet, P.O., daily at 0800
"Click pack"
Occasional ibuprofen for menstrual cramps
Family History mom had anxiety disorder, grandfather was
alcoholic
Mother has anxiety disorder
Father has no major medical issues Maternal grandfather had a history of alcoholism
Social History full time school, lives with roomate, has no job currently, excercizes regulary, inadequate diet drinks 3 to 4 times aweek, four or five drinks at time
College student - Junior.
Single - sexually active, not in relationship at this time. Practices safe sex.
Tobacco: denies present use of tobacco and nicotine use.
Alcohol/Illicit Drug Use: denies any illicit drug use. Uses alcohol at least three times/week. Reports at least two episodes of passing out after drinking in the past month.
CAGE Assessment: Ms. Adler doesn't think others care about her drinking since she mostly drinks with friends. She drinks to feel better or feel nothing, does not think this hurts anyone. No drinking first thing in morning.
https://wgu.shadowhealth.com/assignment_attempts/3763883 2/4
Review of Relevant Systems
right wrist pain GENERAL: Negative for fever, chills, night sweats. Reports occasional fatigue.
HEENT: No visible evidence of trauma. PERRLA.
RESPIRATORY: Negative for shortness of breath, cough, wheezing.
CARDIOVASCULAR: Negative for chest pain, palpitations, edema.
GASTROINTESTINAL: Denies nausea, denies vomiting, constipation, diarrhea.
INTEGUMENTARY: No visible evidence of self- harm.
MUSCULOSKELETAL: Swelling and redness of
(R) wrist due to sprain from recent MVA.
NEUROLOGICAL: Negative for weakness, frequent headaches, dizziness, falls, or changes in coordination. Passed out several times recently from alcohol abuse. No memory surrounding passing out due to ETOH abuse. Tingling in fingers of (R) hand since wrist injury.
1. Explicitly describe the tasks you undertook to complete this exam.
2. Explain the clinical reasoning behind your decisions and tasks.
8/31/2018 Focused Exam: Alcohol Abuse | In Progress Attempt | Shadow Health
Enter your response here...
Save
3. Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional nursing practice.
Enter your response here... [Show Less]