Shadow Health Alcohol Disorder PDF

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Summary

SH Alcohol disorder...

Description

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 process. 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 page.

Documentation Review Nursing Admitting... Mental Status Note SBAR

Nursing Admitting Note Student Response

Chief Complaint

Model Documentation

Rachel Adler 20 y/o female brought into the ED after a car accident driving

Ms. Adler has a sprained (R) wrist due to an MVA caused by impaired driving.

under the influence, her right wrist is injured

She is a self-harm risk and expressed passive suicidal ideation.

History of Present

no hx of present illness

Illness

Rachel Adler is a 20-year-old White woman with a history of alcohol use and anxiety. She was brought to the ER last night by law enforcement after a MVA in which she was noted to be under the influence of alcohol and had an injured her (R) wrist. Assessment in the ER confirmed a sprain of the (R) wrist, and an alcohol level of 0.2% (over the legal limit in the state for individuals under the age of 21) was determined at the scene. Ms. Adler stated she did not know what happened, but was told she received a ticket for DUI. Reported pain level upon arrival to the ER to be 8/10. Pain relief noted when ibuprofen administered. Ms. Adler denies any nausea, vomiting. Admitted to adult mental health unit based on positive assessment for self harm.

Allergies

NKDA, peanuts (mouth and throat become itchy)

Peanuts, reaction is itchy mouth and throat NKDA

Past Medical

No past medical hx

No medical issues Denies use of prescription or recreational drugs, denies tobacco

History

use

Past Surgical

No past surgical hx

No past surgical procedures

Ibuprofen, and birth control

Ortho Tri Cyclen Lo, 1 tablet, P.O., daily at 0800 "Click pack"

History

Medication History

Occasional ibuprofen for menstrual cramps

Family History

Grandfather was an alcoholic, mother has anxiety disorder

Mother has anxiety disorder Father has no major medical issues Maternal grandfather had a history of alcoholism

Social

Reports that she does not care what

History

happens to her anymore (passive suicidal ideation) reports feeling anxious the past 6 months, has not sought treatment/counseling, stressed over parental relationships, school, and grades

College student - Junior. Single - sexually active, not in relationship at this time. Practices safe sex. Tobacco: denies present use of tobacco and nicotine use. Alcohol/Illicit Drug Use: denies any illicit drug use. Uses alcohol at least three times/week. Reports at least two episodes of passing out after drinking in the past month. CAGE Assessment: Ms. Adler doesn't think others care about her drinking since she mostly drinks with friends. She drinks to feel better or feel nothing, does not think this hurts anyone. No drinking first thing in morning.

Review of Relevant Systems

loss of appetite, frequent alcohol use and passes out from drinking

GENERAL: Negative for fever, chills, night sweats. Reports occasional fatigue. HEENT: No visible evidence of trauma. PERRLA. RESPIRATORY: Negative for shortness of breath, cough, wheezing. CARDIOVASCULAR: Negative for chest pain, palpitations, edema. GASTROINTESTINAL: Denies nausea, denies vomiting, constipation, diarrhea. INTEGUMENTARY: No visible evidence of self-harm. MUSCULOSKELETAL: Swelling and redness of (R) wrist due to sprain from recent MVA.

NEUROLOGICAL: Negative for weakness, frequent headaches, dizziness, falls, or changes in coordination. Passed out several times recently from alcoho luse. No memory surrounding passing out due to ETOH use. Tingling in fingers of (R) hand since wrist injury....