Mental Health | Transcript.pdf - Mental Health Results |...

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Unformatted text preview: Mental Health Results | Completed Advanced Pathopharmacology & Physical Assessment for the Nurse Educator - July 2018, NRSG631A -1803A -01 Return to Assignment Your Results Overview Turn In Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 47 out of 48 Objective Data Collection Education & Empathy Documentation Proficiency Level: Proficient Beginning Digital Clinical Experience Score 100% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent. Developing Proficient Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner. Subjective Data Collection Objective Data Collection 0 out of 0 43 out of 44 Education and Empathy 4 out of 4 Time 132 minutes total spent in assignment Interaction with patient 132 minutes Transcript Started: Jul 24, 2018 | Patient Exam Time: 132 min All Lines (109) Interview Questions (82) Statements (27) Exam Actions (0) Good afternoon Ms. Jones. My name is Tally Breitstein and I am here to interview and examine you. Greet 07/24/18 4:41 PM MDT Hey. What brings you here today, Ms. Jones? Question 07/24/18 4:42 PM MDT 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 am sorry to hear you have trouble sleeping Empathize 07/24/18 4:45 PM MDT I appreciate you telling me that. I would like to learn more about your sleeping patterns, then we can talk about ways to resolve it. Educate 07/24/18 4:47 PM MDT OK, I understand. When did you notice you have trouble sleeping? (No matching questions found.) Question 07/24/18 4:47 PM MDT When did your sleep problem start?? Question 07/24/18 4:48 PM MDT This all started almost a month ago. . . it's been happening regularly for about three and a half weeks, I'd say. How often do you have difficulty sleeping? (No matching questions found.) Question 07/24/18 4:49 PM MDT Tell me about your sleeping problem Empathize 07/24/18 4:50 PM MDT Thanks for understanding. Tell me about your sleeping problem Question 07/24/18 4:51 PM MDT 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. That must be hard for you. Empathize 07/24/18 4:51 PM MDT Thanks. Do you have problems falling a sleep? (No matching questions found.) Question 07/24/18 4:52 PM MDT How long does it take you to fall asleep? Question 07/24/18 4:52 PM MDT Lately it's like. . . I get in bed, and then I read for about an hour because I'm worried once I try to fall asleep I won't be able to. Then, once I try to fall asleep, that can take over an hour, sometimes more. This can be frustrating Empathize 07/24/18 4:54 PM MDT I appreciate you saying that. What makes ot easier to fall asleep? Question 07/24/18 4:55 PM MDT 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. Stress can make it difficult to fall asleep. Educate 07/24/18 5:01 PM MDT Alright, thanks for letting me know. Is your trouble sleeping interfere with your daily activities? Question 07/24/18 5:02 PM MDT 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. How many hours do you sleep every night? Question 07/24/18 5:04 PM MDT 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. When you say "out of it" what do you mean? Empathize 07/24/18 5:06 PM MDT Thanks for saying that. When you say "out of it" what do you mean? (No matching questions found.) Question 07/24/18 5:06 PM MDT when you say out of it" what do you mean? (No matching questions found.) Question 07/24/18 5:07 PM MDT what do men when you say you feel out of it? Question 07/24/18 5:08 PM MDT 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. Why do you think you hard time falling asleep? 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. Question 07/24/18 5:10 PM MDT I am sorry you are experiencing these symptoms Empathize 07/24/18 5:12 PM MDT I appreciate you telling me that. Do you wake up after you fell asleep? (No matching questions found.) Question 07/24/18 5:13 PM MDT Do you wake up in the night? Question 07/24/18 5:13 PM MDT Yeah, I wake up during the night a few times, I'd say. How many times do you wake up during the night? Question 07/24/18 5:14 PM MDT I'd say two or three times a night for at least ten minutes each, usually. Do you have hard time sleeping every night? (No matching questions found.) Question 07/24/18 5:15 PM MDT How often do you have trouble sleeping? Question 07/24/18 5:16 PM MDT It's happening most nights, I'd say. Four. . . more like five nights a week. Do you feel anxious? Question 07/24/18 5:17 PM MDT I've never been diagnosed with anxiety or anything. . . I think usually I'm a pretty relaxed person. At least until recently. What makes you feel anxious? I'm stressed now because I can't sleep, but I can't sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that's coming up, and getting a job, and finding my own place to live. . . it's a lot. Question 07/24/18 5:18 PM MDT Yes it is a lot to think about. I understand. Empathize 07/24/18 5:19 PM MDT Thanks for saying that. What symptoms pf anxiety do you have? Question 07/24/18 5:19 PM MDT 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. How do you cope with the stress? Question 07/24/18 5:20 PM MDT Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I'll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should. when you are stressed you experience difficulty sleeping, which causes you to be tired, which may cause increase in stress. Its a cycle. Educate 07/24/18 5:24 PM MDT Thanks for telling me. Do you still using the flovent inhaler? Question 07/24/18 5:26 PM MDT I'm supposed to use it twice a day, and I haven't missed a dose yet. Did you use your proventil inhaler recently? Question 07/24/18 5:26 PM MDT Well, I use my Flovent inhaler every day, and when my breathing acts up, I just use two puffs from my rescue inhaler. when was the last time you used you rescue inhaler? I don't think I've needed it for . . . Wow, it's been about nine months. Question 07/24/18 5:27 PM MDT It is important to check the expiration date of the medications you are taking, to make sure the expiration date has not passed. Educate 07/24/18 5:29 PM MDT That makes sense. What medications are you taking other then the flovent and proventil? (No matching questions found.) Question 07/24/18 5:30 PM MDT What other medications are you taking? Question 07/24/18 5:30 PM MDT I'm just taking my daily inhaler right now. I haven't needed my rescue inhaler in awhile. I guess I take Advil sometimes if I have a headache, but that's it. Do you take any sleeping aides? (No matching questions found.) Question 07/24/18 5:31 PM MDT Do you take mediation to sleep? Question 07/24/18 5:32 PM MDT I haven't tried taking anything to sleep--I would really rather avoid having to take medication if possible. you are allergic to cats Question 07/24/18 5:33 PM MDT Yeah, my cousin has them, and I get really allergic around them. taking sleeping aides may make it difficult to wake up in the morning and may cause you to feel foggy. Educate 07/24/18 5:35 PM MDT Sure, I think I understand what you mean. I understand how hard it is for you to feel tired during the day, and how hard it is to accomplish daily tasks. Thanks. Empathize 07/24/18 5:36 PM MDT Do you have history of psychiatric illness? Question 07/24/18 6:19 PM MDT No. Have you ever had desperate thoughts? (No matching questions found.) Question 07/24/18 6:21 PM MDT are you loosing interest or pleasure in life? (No matching questions found.) Question 07/24/18 6:21 PM MDT are you loosing interest life? (No matching questions found.) Question 07/24/18 6:22 PM MDT Do you feel depressed? Question 07/24/18 6:22 PM MDT I don't think I'm depressed. Do you feel you want to hurt yourself? (No matching questions found.) Question 07/24/18 6:23 PM MDT Do you feel like hurting yourself? Question 07/24/18 6:24 PM MDT No, I've never wanted to hurt myself. Did you think about suicide? (No matching questions found.) Question 07/24/18 6:24 PM MDT do you have thoughts about ending your life? Question 07/24/18 6:25 PM MDT No, I've never thought about that. That is good Empathize 07/24/18 6:25 PM MDT Thanks for saying that. If you ever have thought of hurting yourself, you need to let someone you trust know or seek professional help. Educate 07/24/18 6:27 PM MDT Alright, thanks for letting me know. Do you have any trauma in your past? (No matching questions found.) Question 07/24/18 6:27 PM MDT Have you had trauma? Question 07/24/18 6:28 PM MDT About a month ago. I got a checkup after a minor fender bender but everything was fine. Is there any past trauma? (No matching questions found.) Are you employed? Question 07/24/18 6:29 PM MDT Question 07/25/18 12:22 PM MDT I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. I understand you are a student as well. School and work can be difficult. Empathize 07/25/18 12:25 PM MDT Thanks for saying that. What are you studying? Question 07/25/18 12:25 PM MDT I'm going to get my bachelor's in accounting. Where do you go to school? I go to Shadowville State College. Question 07/25/18 12:25 PM MDT Do you have any hobbies? Question 07/25/18 12:26 PM MDT I read a lot, especially since I bought one of those e-book readers. My friends and I have thought about starting a book club actually. Oh, and there's these free talks at church that I like to go to if I have time. I watch TV, but usually on DVD or streaming. I like to marathon the shows I really like. I'm really interested in documentaries, too. I understand that you are busy and have little free time, However exercise is important and it helps relieve stress. Even small amount of exercise such as walking helpful. Educate 07/25/18 12:31 PM MDT Alright, thanks for letting me know. Did you have problems with the police? (No matching questions found.) Question 07/25/18 12:32 PM MDT Did you have legal problems? Question 07/25/18 12:33 PM MDT No way. Did you serve in the military? Question 07/25/18 12:34 PM MDT No, I've never been in the military. Who do you live with? Question 07/25/18 12:35 PM MDT There's three of us at home. . . me, my mom, and my sister. Is there problem at home? (No matching questions found.) Question 07/25/18 12:36 PM MDT Do you feel safe at home? Question 07/25/18 12:36 PM MDT Yeah, I feel safe at home. Do you have good relationship with you mom and your sister? Question 07/25/18 12:37 PM MDT We have a good relationship--we've become much more of a team since I moved back in, but she's good about respecting that I have my own life going on too. Do you believe in God? Question 07/25/18 12:39 PM MDT Yes, absolutely. Do you believe in spirituality? (No matching questions found.) Question 07/25/18 12:39 PM MDT What is your religious affiliation? Question 07/25/18 12:40 PM MDT I'm Baptist, and my faith is a big part of my life. Have you ever used drugs? Question 07/25/18 12:41 PM MDT I used to smoke pot, but I don't do that anymore. I haven't tried any other drugs. Thank you for letting me know about the marijuana use. Empathize 07/25/18 12:44 PM MDT I appreciate you telling me that. Marijuana withdrawal symptoms include irritability, mood changes, difficulty sleeping and restlessness. Educate 07/25/18 12:46 PM MDT OK, I understand. When dod you stop using marijuana? Question 07/25/18 12:46 PM MDT About. . . eight years ago? I think I was twenty or twenty one when I stopped. Do you drink alcohol? Question 07/25/18 12:47 PM MDT I do sometimes, yeah, when I go out with my friends. It is important not to drink alcohol and drive. Educate 07/25/18 12:48 PM MDT Thanks for telling me. Do you drink and drive? Question 07/25/18 12:48 PM MDT We usually take a cab when we go out. Thank you for telling me that/ Empathize 07/25/18 12:48 PM MDT Thanks for understanding. Do you smoke? Question 07/25/18 12:49 PM MDT No. I think it's gross. Do you abuse prescription drugs, such as pain medications? (No matching questions found.) Question 07/25/18 12:50 PM MDT Do you abuse prescription drugs,? Question 07/25/18 12:50 PM MDT No! I don't know why I'd want to take someone else's prescriptions. . . I hate having to take my own medicines. Prescription drug abuse is dangerous and may lead to addiction Educate 07/25/18 12:52 PM MDT Sure, I think I understand what you mean. Are you ina relationship? Question 07/25/18 12:53 PM MDT No, I'm not in a relationship right now. have you had sex? Question 07/25/18 12:54 PM MDT Um, yeah, I have. When having sex you should uses protection to prevent sexually transmitted infections and unwanted pregnancy. Educate 07/25/18 12:56 PM MDT That makes sense. Where you in an abusive relationship? Question 07/25/18 12:56 PM MDT No. I've been lucky, my boyfriends have always been really nice guys. Is there family history of psychiatric illness? Question 07/25/18 12:58 PM MDT No. They're crazy, but nobody's diagnosed with anything. Is there any trauma in your past? 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. Where there symptoms related to the death of your father? (No matching questions found.) Question 07/25/18 1:07 PM MDT Question 07/25/18 1:09 PM MDT i am sorry to hear of the passing pf your father. Empathize 07/25/18 1:10 PM MDT Thanks for saying that. How did you deal with is passing? (No matching questions found.) Question 07/25/18 1:10 PM MDT How are you coping with the death of your father? Question 07/25/18 1:11 PM MDT Right after Dad died I stayed really busy, helping Mom with the funeral and insurance papers and financial stuff. She was really sad, just crying all the time and sleeping a lot, and getting things done for her kind of gave me a sense of control, you know? And I had my friends and my church to turn to when I needed to talk. I don't know what I would have done without them, honestly. Little by little, as time went on, I felt better. I know God is taking care of Dad, and that comforts me. Do you have violent thoughts? Question 07/25/18 1:11 PM MDT No, never. Was there any other significant trauma in the past? (No matching questions found.) Question 07/25/18 1:14 PM MDT Was there any other trauma in the past? (No matching questions found.) Question 07/25/18 1:14 PM MDT Where you involved in traumatic event? (No matching questions found.) Question 07/25/18 1:15 PM MDT Was there any trauma in your life? (No matching questions found.) Question 07/25/18 1:16 PM MDT Was there any history of trauma ? (No matching questions found.) did you suffer trauma in the past ? Question 07/25/18 1:17 PM MDT Question 07/25/18 1:18 PM MDT About a month ago. I got a checkup after a minor fender bender but everything was fine. where you abused as a child? Question 07/25/18 1:19 PM MDT No, never. I am happy to hear that. Empathize 07/25/18 1:20 PM MDT I appreciate you saying that. I have few more questions to complete the interview Educate 07/25/18 1:21 PM MDT Sure, I think I understand what you mean. Do you drink coffee? Question 07/25/18 1:21 PM MDT Never. I don't like it. Too bitter for my taste. Do you drink energy drinks? Question 07/25/18 1:22 PM MDT I've tried a few, but no. I don't really like them. I think your trouble sleeping is related to exam anxiety That makes sense. Educate 07/25/18 1:23 PM MDT Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2018 ...
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