Focused Exam: Bipolar Disorder Results | Completed
Mental Health Concepts in Nursing - January 2020, nur3525-ku_wpb_nur3525d1101132020
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Overview
Subjective Data Collection: 69 of 69 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
Documentation
m
er as
SBAR
Category Scored Items Patient Data
co
Reflections
eH w
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yield
o.
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
rs e patient's case.
ou urc
Chief Complaint
o
Asked about chief complaint Reports being brought in by police
aC s
vi y re
History of Present Illness
Followed up on incident Reports looking into cars for government agents
ed d
chasing him
Reports having been in a grocery store parking lot
ar stu
Reports knowing the police stopped him for
running around and looking in cars
Denies having hurt himself or others
Denies having done anything illegal
is
Th
Followed up on government agents Reports government is trying to imprison him for
being enlightened
Reports government sees his enlightenment as a
threat to their secrets
sh
Asked about anxiety or paranoia Denies anxiety or paranoia
Reports high awareness of government agents
chasing him
Asked about hallucinations Denies hallucinations
Asked about most recent substance use Reports last substance use was about four days
ago
This study source was downloaded by 100000829943187 from CourseHero.com on 09-26-2021 17:01:53 GMT -05:00
Reports last substance use was cocaine
, Asked about recent sleep history Reports not having slept for four days
Asked about current energy levels Reports current extremely high energy
Asked about current mood Reports current euphoria
Asked about onset of energy and mood Reports high energy began a week ago
Reports euphoria began a week ago
Past Medical History
Asked about existing health conditions Reports being diagnosed with depression
Asked about typical moods Reports periods of euphoria
Reports periods of depression
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Asked about typical energy levels Reports periods of extremely low energy
co
Reports periods of extremely high energy
eH w
o.
Asked about frequency of mood changes Reports mood changes occur a couple of times a
rs e year
ou urc
Asked about last period of depression Reports last depressive period ended a couple
months ago
o
Reports last depressive period was a long one
aC s
vi y re
Asked about details of depression diagnosis Reports being diagnosed by psychiatrist
Reports diagnosed 3 years ago
ed d
Asked about reason for seeing psychiatrist Reports being made to see the psychiatrist
following a suicide attempt
ar stu
Asked about how depression was treated Reports psychiatrist prescribed antidepressants
is
Asked about hospitalizations Reports being hospitalized after suicide attempt
Th
Reports being hospitalized 3 years ago
Asked about allergies Denies allergies
sh
Home Medications
Asked about effectiveness of medication Reports antidepressants were not effective
Reports antidepressants caused side effects
Reports stopping the antidepressant regimen
Reports not consulting a healthcare provider
before stopping regimen
This study source was downloaded by 100000829943187 from CourseHero.com on 09-26-2021 17:01:53 GMT -05:00
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