NURSING ASSESSMENT & NOTES
9123 Neuro/Cognitive: Alert, orientedx 4. Speech clear, pressured
1710
Integumentary: Numerous superficial cuts to the bilateral thighs
Bleeding controlled
Psychosocial: iad breakup with boyfriend last night. *He says I'm too
clingy.” Clean, non-disheveled. Reports that she made a statement that
she would take all of her psych medications on social media to "end it
all" Client now states she is not suicidal.
, Nursing Other
9/23 1700 Client Inform:
Medical History:
« Depression
« Generalized anxiety disorder
« Borderline personality disorder
« Pehic inflammatory disease
« Gonorrhea
« Anorexia nervosa
Mental Health History:
« Two suicide attempts
« Two admissions to local mental health facilty
Social History:
+ Smoke 1 pack/day cigarettes
+ Occasional mariuana use
« History of IV drug abuse
Medication:
« Topiramate 75 mg by mouth twice daily
« Haloperidol 3 mg by mouth three times daily
9/23 1700 Personal Preferences:
« Relationship: multiple partners — male and female
« Cultural: none
« Spirtual: none
« Identified Gender: Female
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Millenialnurse. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $23.99. You're not tied to anything after your purchase.
