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Mental Health Results | Turned In Advanced Health Assessment - Summer 2021, NUR 703 Return to Assignment (/assignments/486493/)

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Transcript

Transcript Started: May 27, 2021 | Total Time: 70 min Subjective Data Collection All Lines (194)

Interview Questions (191)

Statements (3)

Exam Actions (0)

Objective Data Collection Education & Empathy

Hey.

Documentation

what brings you in today

Question 05/27/21 10:05 PM EDT

I decided to come in because I'm tired all the time now. . . I have this really important exam coming up, and I'm stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

why did you decide to seek treatment

Question 05/27/21 10:06 PM EDT

I decided to come in because I'm tired all the time now. . . I have this really important exam coming up, and I'm stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

I appreciate you telling me that.

how long have you been having trouble sleeping

Question 05/27/21 10:08 PM EDT

This all started almost a month ago. . . it's been happening regularly for about three and a half weeks, I'd say.

how many nights a week do you have trouble sleeping

Question 05/27/21 10:08 PM EDT

It's happening most nights, I'd say. Four. . . more like five nights a week.

05

can you describe how you feel before bed (Clarified to How do you feel just before bed?.)

Question DT

Support

It's like. . . once it gets close to bed time, I start feeling on edge, even though I've been pretty tired all day. Then once the light's off and I try to sleep, my mind just starts racing, and I think about all the things in the future that I'm stressed out about. (Clarified to how I feel just before bed.)

what makes it harder to sleep

Question 05/27/21 10:12 PM EDT

Basically, the more I think about what I'm worried about, the worse it is. Sometimes I can distract myself and not let myself start thinking about all the things that stress me out, but that's been rare.

do you take naps

Question 05/27/21 10:13 PM EDT

I'm not really a big nap person--if I fall asleep, I want to sleep for hours, not wake up in twenty minutes feeling groggy. Plus I don't have time for them, anyway.

do you drink caffeine

Question 05/27/21 10:13 PM EDT

Well. . . I drink diet Coke. Mostly to wake up.

how much diet coke do you drink each day

Question 05/27/21 10:13 PM EDT

I usually drink about four Diet Cokes, and maybe a glass of water or two. I have been drinking a lot more water lately, though.

when do you have your last caffeinated drink

Question 05/27/21 10:14 PM EDT

I know caffeine can make it hard to sleep, so I try to only drink it in the morning and early afternoon. . . I never have caffeine after 4 PM.

do you drink alcohol before bed

Question 05/27/21 10:14 PM EDT

I haven't been drinking at all lately. I have too much to get done.

do you use drugs before bed

Question 05/27/21 10:15 PM EDT

No. . . I don't do drugs.

do you take any medications for sleep

Question 05/27/21 10:15 PM EDT

I haven't tried taking anything to sleep--I would really rather avoid having to take medication if possible.

have you tried any supplements or herbs for sleep (No matching questions found.)

Question 05/27/21 10:15 PM EDT

have you taken any supplements for sleep (Clarified to Have you taken any botanical products?.)

Question 05/27/21 10:15 PM EDT

No, I don't take anything herbal. (Clarified to if I have taken botanical products.)

have you taken supplements in the past (Clarified to How long have you taken vitamins?.)

Question 05/27/21 10:16 PM EDT

I don't take vitamins or supplements. (Clarified to how long I have taken vitamins or supplements.)

do you think your sleep problems could be related to breathing issues

Question 05/27/21 10:16 PM EDT

My sleep problems definitely aren't related to my breathing. . . I haven't been having any breathing problems, really, since I started the daily inhaler.

what helps you sleep

Question 05/27/21 10:16 PM EDT

Basically the only way I get to sleep easily is if I manage to feel less stressed out--sometimes I can sort of turn my thoughts away from what I'm worried about by distracting myself with something, like thinking about what I'm going to wear the next day or something like that. I'd rather avoid having to take medication if possible. Taking deep breaths can help a little, too.

have you tried meditation

Question 05/27/21 10:17 PM EDT

I haven't. I could, I guess. [AUDIO COMING SOON]

tell me about your sleep hygiene (Clarified to Can you tell me about your sleep history?.)

Question 05/27/21 10:17 PM EDT

Well. . . the only other time I've had sleep problems was right after Dad died. It felt a little like this, with my mind racing, but honestly, not as bad. Other than that month or two, I've always been a really good sleeper. I could fall asleep right away, and then I'd sleep like a log. (Clarified to to tell you about my sleep history.)

have you been diagnosed with depression

Question 05/27/21 10:18 PM EDT

I was pretty sad after Dad died, but I wouldn't say it was, like, true depression. I definitely wasn't diagnosed with it or anything.

have you been diagnosed with anxiety

Question 05/27/21 10:18 PM EDT

No.

do you exercise

Question 05/27/21 10:18 PM EDT

I just don't have time to exercise, honestly.

how does your lack of sleep affect your daily life

Question 05/27/21 10:18 PM EDT

Well. . . I'm tired all day, and I feel kind of out of it. That makes it hard to focus and get things done, especially when I try to study for my exam coming up. It's pretty frustrating.

have you been falling asleep when you dont mean to

Question 05/27/21 10:19 PM EDT

No, though I do feel groggy during the day.

what do you mean when you say you feel out of it

Question 05/27/21 10:19 PM EDT

It's like. . . I just feel slowed down and tired all the time from not sleeping. It's harder to focus, or get things done efficiently. . . I'm just generally less sharp.

can you tell me about how your anxiety feels

Question 05/27/21 10:20 PM EDT

When I feel anxious, it's like. . . I'm kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about.

do you have any heart palpitations

Question 05/27/21 10:20 PM EDT

Sometimes when I really start to stress out it will feel like my heart is beating a little faster, but not often, and if I think about taking deep breaths it will go away. do you even have an impending sense of doom (Clarified to Do you have a sense of impending doom?.)

Question 05/27/21 10:20 PM EDT

I mean, I worry about the future, but I wouldn't say I feel doomed. (Clarified to if I have a sense of impending doom.)

have you been having panic attacks

Question 05/27/21 10:20 PM EDT

I've never had a panic attack, no.

have you been having trouble concentrating

Question 05/27/21 10:21 PM EDT

I usually have no trouble concentrating, but I'm so tired and out of it lately it's harder to really focus.

do you feel restless

Question 05/27/21 10:21 PM EDT

Not generally, but right before bed I do start to feel kind of restless.

do you feel irritable

Question 05/27/21 10:21 PM EDT

I feel like little setbacks annoy me more since my sleep trouble started. . . like if I can't find my keys, or I get stuck at a red light, it's harder for me to be patient about it.

how does your anxiety interfere with your daily life

Question 05/27/21 10:21 PM EDT

Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life.

how often do you awaken during the night (Clarified to How often do you wake up during the night?.)

Question 05/27/21 10:21 PM EDT

I'd say two or three times a night for at least ten minutes each, usually. (Clarified to how often I wake up during the night.)

how do you feel when you wake up in the morning

Question 05/27/21 10:22 PM EDT

Ugh, horrible, honestly. Just not rested, and out of it, and groggy. . . waking up has been really hard lately.

when do you go to bed

Question 05/27/21 10:22 PM EDT

I get in bed around midnight, but I haven't been able to fall asleep that early in a while.

when do you fall asleep

Question 05/27/21 10:22 PM EDT

I get into bed around midnight, but then I'll read because I can feel myself start to stress about stuff and I need a distraction. So I'll actually turn of the light and close my eyes around 1 or so, and then I won't fall all the way asleep for another hour and a half, two hours, usually. Sometimes, if I really start stressing out, I'll even turn the light back on and read more until I feel more wound down.

what do you usually do before bed

Question 05/27/21 10:23 PM EDT

I usually eat dinner, then I try to study for a few hours or do other schoolwork. Around midnight, I get into bed, and I'll read to try to distract myself from feeling nervous until I feel like I can fall asleep.

do you watch the tv or use the computer before bed

Question 05/27/21 10:23 PM EDT

No, I usually just read a book right before bed.

how many hours a night do you sleep

Question 05/27/21 10:23 PM EDT

I've always tried to get 8, and I've done a pretty good job of it, but lately most nights I get 4, maybe 5 hours.

Thanks.

can your describe where you sleep

Question 05/27/21 10:24 PM EDT

Uh. . . I sleep in bed. In my bedroom.

how do you feel when youre stressed

Question 05/27/21 10:25 PM EDT

Usually when I'm stressed I just get kind of scattered and distracted, so if I stay organized, I'm fine. Lately, though, it's just these racing thoughts of everything I'm worried about, and it's harder to control.

are you taking any new medications

No, I'm still just taking the Flovent inhaler twice a day, and then I have my albuterol to use if I need it, though that hasn't happened really.

Question 05/27/21 10:25 PM EDT

do you have a history of psychological problems (Clarified to Do you have a history of psychiatric illness?.)

Question 05/27/21 10:25 PM EDT

No. (Clarified to if I have a history of psychiatric illness.)

have you ever been admitted to the hospital for psychological reasons (Clarified to Have you had to go to the hospital for a psychiatric disorder?.)

Question 05/27/21 10:26 PM EDT

No, luckily that's never happened to me. (Clarified to if I have ever been hospitalized for a psychiatric disorder.)

do you feel safe at home

Question 05/27/21 10:26 PM EDT

Yeah, I feel safe at home.

what do you do for work

Question 05/27/21 10:26 PM EDT

I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up.

are you married

Question 05/27/21 10:26 PM EDT

No, I never have been.

are you sexually active

Question 05/27/21 10:26 PM EDT

No, I haven't been in a while.

any thought of hurting yourself or others (Clarified to Have you ever thought about harming yourself or others?.)

Question 05/27/21 10:26 PM EDT

No, I don't have thoughts like that. (Clarified to if I have ever had thoughts of harming myself or others.)

have you ever heard voices

Question 05/27/21 10:27 PM EDT

No. At least, I hope not!

is your mood unstable (Clarified to Do you have sudden changes in your mood?.)

Question 05/27/21 10:27 PM EDT

I mean, I'm feeling stressed out, but I wouldn't say I'm having mood swings or anything. (Clarified to if I am having mood changes.)

do you have anger issues

No, I try to be patient. With my family, especially.

Question 05/27/21 10:27 PM EDT

have you ever not slept for days at a time (No matching questions found.)

Question 05/27/21 10:27 PM EDT

have you ever gone days without sleep (No matching questions found.)

Question 05/27/21 10:28 PM EDT

have you ever not slept for more than a day (No matching questions found.)

Question 05/27/21 10:28 PM EDT

tell me more about your stress level (Clarified to What is your stress level?.)

Question 05/27/21 10:28 PM EDT

I'm pretty stressed, honestly. I'd say my stress level is high. (Clarified to how my stress level is.)

have you taken OTC meds to help you sleep (Clarified to Have you been taking over the counter sleep medications?.)

Question 05/27/21 10:28 PM EDT

No, I haven't tried taking anything to sleep. I'd rather avoid having to take medication if possible. (Clarified to if I have been taking over the counter sleep medication.)

does your family have a history of mental illness

Question 05/27/21 10:29 PM EDT

No. They're crazy, but nobody's diagnosed with anything.

tell me about your support system

Question 05/27/21 10:29 PM EDT

I'd say my family--Mom, my sister, and my brother--are who I'm closest to.

do you feel lonely

Question 05/27/21 10:29 PM EDT

No, I'm not lonely. I haven't had a boyfriend in awhile, but I couldn't feel lonely with the family and friends that I have.

have you had any new allergies

Question 05/27/21 10:29 PM EDT

Nope.

any changes in appetite

Question 05/27/21 10:30 PM EDT

I'm feeling less hungry lately, actually. . . I think not sleeping is making me feel a little queasy during the day.

how much water do you drink

Question 05/27/21 10:30 PM EDT

I don't really keep track of how much, but I've been drinking a lot of water lately. Way more than usual.

do you feel thirsty all the time

You know, I did notice lately that I've been really thirsty.

Question 05/27/21 10:30 PM EDT

have you been monitoring your blood glucose

Question 05/27/21 10:30 PM EDT

I have a monitor at home, but to be honest I don't really use it that often.

does your anxiety affect your activities

Question 05/27/21 10:31 PM EDT

Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life.

does not getting enough sleep run in your family (No matching questions found.)

Question 05/27/21 10:31 PM EDT

does your family have a history of sleep problems

Question 05/27/21 10:31 PM EDT

I don't think anyone in my family has trouble sleeping. Just me. [AUDIO COMING SOON]

do you smoke

Question 05/27/21 10:32 PM EDT

No. I think it's gross.

what is your level of education

Question 05/27/21 10:32 PM EDT

Well, in about a month I'll be a college graduate, as long as I manage to get some sleep!

do you have adequate transportation (No matching questions found.)

Question 05/27/21 10:32 PM EDT

are you financially stable

Question 05/27/21 10:33 PM EDT

I make a fine living, especially since I don't have to pay rent. I've had to be careful with money so I have enough for tuition and books, but that will be over soon.

do you feel that you can adequately access healthcare

Question 05/27/21 10:33 PM EDT

I have health insurance through my job, so I can go to the doctor if I need to. It's always a hassle though, so I try to avoid it unless I really have to like right now.

is your neighborhood safe

Question 05/27/21 10:33 PM EDT

Um, yeah, it's pretty safe where we are.

are you close with your family

Question 05/27/21 10:33 PM EDT

Family's a big part of my life, so I'm pretty close to everyone. Mom and I have gotten a lot closer since Dad died, too. Now we're kind of a team.

does your family have health problems

Question 05/27/21 10:34 PM EDT

My mom has some issues, and I think some of my grandparents did, too.

what health issues does your mom have

Question 05/27/21 10:34 PM EDT

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

have you had difficulty falling asleep before

Question 05/27/21 10:34 PM EDT

Well. . . the only other time I've had sleep problems was right after Dad died. It felt a little like this, with my mind racing, but honestly, not as bad. Other than that month or two, I've always been a really good sleeper. I could fall asleep right away, and then I'd sleep like a log.

do you have bipolar disorder

Question 05/27/21 10:34 PM EDT

No.

do you have schizophrenia

Question 05/27/21 10:35 PM EDT

No, I don't.

do you have obsessive compulsive disorder

Question 05/27/21 10:35 PM EDT

No. I feel really lucky that I haven't had to deal with that.

have you taken psychotropic meds

Question 05/27/21 10:35 PM EDT

No, luckily I've never needed that.

do you have symptoms of depression

Question 05/27/21 10:35 PM EDT

No. . . I don't think so.

do you have difficulty making decisions

Question 05/27/21 10:36 PM EDT

Only in the sense that, like, everything I do is a little harder because I'm out of it from not sleeping.

do you feel guilty for no reason

Question 05/27/21 10:36 PM EDT

No, I haven't been feeling guilty.

do you feel hopeless

I don't feel hopeless, just frustrated and stressed out.

Question 05/27/21 10:...