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TinaJones_Subjective_Mental Health _ Shadow Health
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8/28/2019 Mental Health | Completed | Shadow HealthMental Health Results | Turned In
Advanced Health Assessment - Summer 2019, NURS 5305.
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Your Results Lab Pass
Overview
Subjective Data Collection: 44 of 44 (100.0%)
Transcript
Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important information, found.
including Pro Tips and Example
Education & Empathy
Questions.
Documentation
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports difficulty sleeping and "feeling
nervous"
Reports seeking treatment because she
has an upcoming exam and feels "too foggy
to study"
Reports excessive worry and "racing
thoughts" before bed
History of Present Illness
Asked about onset and duration of Reports difficulty sleeping began 3 1/2
symptoms weeks ago
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, 8/28/2019 Mental Health | Completed | Shadow Health
Reports sleep difficulties have been
occurring regularly during past 3 1/2 weeks
Asked about frequency of symptoms Reports difficulty sleeping at least four or
five times a week
Asked about aggravating factors Reports sleeping becomes more difficult
when she can not redirect her thoughts from
the things she is worried about
Denies naps during the day
Reports drinking caffeine to stay alert
Reports stopping caffeine use after 4 P.M.
Denies alcohol use before bed
Denies drug use before bed
Reports respiratory problems are
controlled and not interfering with sleep
Asked about relieving factors Reports sleeping more easily if she can
distract herself from her "racing thoughts"
Reports no exercise
Asked about impact of sleeping problems Reports feeling tired and "out of it" most of
on daily living the time during the day due to lack of sleep
Reports no increased chance of drifting off
during the day despite lack of sleep
Followed up about patient's experience Reports feeling slowed down and tired,
feeling "out of it" having trouble focusing, and generally
feeling "less sharp"
Asked about anxiety symptoms Reports feelings of anxiety as "thoughts
she can't turn off" and "being on edge"
Reports worry about the future, but no
sense of impending doom
Reports no panic attacks
Reports difficulty concentrating due to
fatigue from lack of sleep
Reports only restlessness occurs just
before bed
Reports slight irritability due to fatigue
Asked about impact of anxiety on daily Reports stress only interferes with daily
living life because it interrupts her sleep
Reports stress does not prevent her from
completing her usual activities
Asked about sleep quality Reports falling asleep often takes more
than an hour
This study source was downloaded by 100000839306532 from CourseHero.com on 02-04-2022 05:58:23 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/5169784 2/7
https://www.coursehero.com/file/45268464/TinaJones-Subjective-Mental-Health-Shadow-Healthpdf/
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