Linda Waterfall Documentation .docx - Mental Health Case...

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Mental Health Case: Linda WaterfallDocumentation Assignments1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment.Ms. Waterfall is having increased respiratory rate of 24 breath per minute, difficulty in concentration secondary to anxiety and restlessness. She denies chest pain but is having shortness of breath.2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment.My assessment indicated the patient is experiencing anxiety related to past traumatic events regarding her mother death from surgery complications. Ms. Waterfall is expressing excessive worry and concern. She stated that she could not find her medicine bag and how she desperately needed it. It is essential to her beliefs that she has her medicine bag, as she said her mother’s medicine bag was lost when she was in the hospital. Ms. Waterfall said that surgery can not be performed without the medicine bag. She is very worried about the cancer and losing her breast. Ms. Waterfall also stated she did not want her cousin, Alice, to leave her side. I explained to the patient that Alice could leave to get coffee if she wanted to and I would keep her company. 3. Referring to your feedback log, document all nursing care provided and Ms. Waterfall’s response to this care.

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