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NUR 355 Shadow Health Alcohol Disorder Notes

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This is a comprehensive and detailed note on Shadow Health Alcohol Disorder for Nur 355. *Essential Study Material!! *Contains Vital info!!

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  • October 9, 2024
  • 5
  • 2021/2022
  • Class notes
  • Prof. anthony
  • All classes

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Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and
improve as a clinician and gives your instructor insight into your learning process. This reflection
activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.




Documentation Review
Nursing Admitting...
Mental Status Note
SBAR


Nursing Admitting Note

Student Response Model Documentation




Chief Rachel Adler 20 y/o female brought Ms. Adler has a sprained (R) wrist due
Complaint into the ED after a car accident driving to an MVA caused by impaired driving.
under the influence, her right wrist is She is a self-harm risk and expressed
injured passive suicidal ideation.

, History of no hx of present illness Rachel Adler is a 20-year-old White
Present woman with a history of alcohol use
Illness 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.




Allergies NKDA, peanuts (mouth and throat Peanuts, reaction is itchy mouth and
become itchy) throat

NKDA

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