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Focused Exam_ Alcohol Use Disorder _ In Progress Attempt _ Shadow Health_SBAR.
- Institution
- California State University - Los Angeles
Focused Exam_ Alcohol Use Disorder _ In Progress Attempt _ Shadow Health_SBAR.
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By: ProfGoodlucK • 9 months ago
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Focused Exam: Alcohol Use Disorder (Part 2 of 3)BSN Psychiatric and Mental Health Nursing - Feb 2020 Return to Assignment (/assignments/306546/)
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 proces
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 p
Documentation Review
SBAR
Student Response Model Documentation
1. Situation Rachel Adler is a 20-year-old female motor vehicle accident
victim with a sprained right wrist. W as admitted with a high
blood alcohol level. Patient does not acknowledge problem
with alcohol.Rachel Adler is a 20-year-old White woman admitted from
ER last night after a MV A related to alcohol use. She
sustained a (R) wrist sprain during the accident and voice
lack of concern for her personal safety , which is why they
admitted her to the psych unit.
2. Background Patient was drinking at a party last night when she became
upset with a friend. She had approximately five drinks but is
unsure. She drove away intoxicated and became involved in a
MVA at approximately 2200 that caused a sprained right wrist.
Current pain is mild, constant ache in right wrist. Pain is
aggravated with movement and lifting of objects. Ibuprofen and
sling improve pain levels. Patient admits to ideas of self-harm
when driving last night, feeling as though "it would be easier if
it was all over ." Patient was aware she was endangering
others, but she has no desire to harm others. Patient has not
tried to cut down on drinking. Believes people don't know or
don't care that she drinks. Drinks alcohol to "let go" when she
feels "overwhelmed." Drinking makes her "feel better ." She
denies drinking first thing in the morning. She has a peanut
allergy - experiences mouth and throat pruritis.Ms. Adler has a history of alcohol use, but no previous ove
suicidal attempts. She reports a great deal of stress relate
college, her relationship with her mother , and self-esteem
issues surrounding academic performance. After her accid
last evening she stated she did not care what happened to
her. Based on her reckless behavior and intoxication she w
admitted for treatment of ET OH use and suicidal ideation.
3. Assessment The patient has mild pain in right wrist. No other adverse
conditions were noted. Patient tests positive for possible
alcohol abuse. Patient has had suicidal ideations.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 anx
when questioned about her alcohol use and her ability to s
safe. Other than the wrist sprain, she is in good general
health. She does have a peanut allergy , but no medication
allergies.
4. Recommendation Patient should be monitored for suicidal thoughts and safety .
Patient should be educated on the risks of alcohol and the
dangers of driving intoxicated.Based on my assessment, we need to follow up today with
completing an assessment for suicidal ideation and make she is on the roster for q 15 min safety checks. As far as h
therapy for today , there is a team meeting at 10 AM to dis
her care plan and she should meet with the therapist at 1 1
The unit AA meeting is scheduled at 4 PM and she should
attend that session as well.Nursing Admitting...
Mental Status Note
SBAR
What did you learn about assessing a patient with mental illness? How can you apply this
to your clinical practice when working with these types of patients? This study source was downloaded by 100000829957125 from CourseHero.com on 10-04-2021 02:32:26 GMT -05:00
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