1/6/2020 Focused Exam: Depression | In Progress Attempt | Shadow Health https://app.shadowhealth.com/assignment_attempts/5888138 1/2 Focused Exam: Depression (Part 2 of 2) Therapeutic Intervention III - Winter 2020, NUR 304 R eturn to Ass ignment (/assignments/288275/) Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor i nsight 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 N ursin g Admitting... Mental Status Note SBAR Student Response Model Documentation SBAR 1. Situation 86 y/o female patient admitted for extended physical exhaustion Abigail Harris is an 86 -year-old African American woman come into the ER today with weakness and fatigue. She seems to have worsening depression, but there are sever symptoms that overlap her hypothyroidism. 2. Backgro und Admitting diagnosis: depression Secondary diagnosis: diabetes, hypothyroidism No known allergies No signs of abuse. Has family who takes care of her at home. Patient states she has solid support from family. -Insulin aspart 16 units inj 2x/daily w/ meals -insulin glargine 45 units inj 1x/daily -levothyroxine 50 mcg PO 1x/daily -venlafaxine XR 150 mg PO 1x/daily -zolpidem 5 mg PO 1x/daily at bedtime if can't sleep -Pt lost 9lb over last month -HEENT: normal -Respiratory: SOB when walking around house -Cardiovascular: Normal -Skin, hair, nails: brittle nails, dry skin, tenting present -Gastrointestinal : -Musculoskeletal: mild aching joint pain -Neurological: dizziness 2 -3x/week, potential fall risk during occurrence Patient reports thoughts of 'not wanting to feel alive' but no suicidal or self -harm ideations Shows sound judgement, awareness, and willingness to seek treatment Patient successfully performed cognition tests for memory, abstract thinking, and visuospatiality Mrs. Harris has a history of diabetes and depression, with recent history of nearly falli ng due to dizziness and unsteadiness. She has been taking her daytime insulin th she doesn't feel like eating. She has very poor energy an appetite.
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