Racheal Adler Shadow Health Alcohol Abuse Subjective Interview And Sbar, Exams of Nursing

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Racheal Adler Shadow Health Alcohol Abuse Subjective Interview And Sbar

Rachel Adler – ETOH

Chief Complaint Finding: Established chief complaint and reason for admittance Finding: Reports car accident (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Why were you admitted? Finding: Reports injury (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: What caused your injury? Finding: Reports passive suicidal ideation (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: What brings you in today?

History of Present Illness Finding:

Finding: Reports loss of consciousness (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did you lose consciousness during the car accident? Finding: Reports being unsure of how the accident happened (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you know what caused the car accident? Finding: Reports wearing seatbelt (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Were you wearing a seatbelt? Finding: Reports being the driver - no other passengers in car (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Who was driving before the car accident? Finding: Reports was told she would get a ticket for DUI (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question:

What caused the car accident? Finding: Followed up on alcohol use just prior to car accident Finding:

amount of pain they may be experiencing. Example Question: Did you know you were too drunk to drive? Finding: Reports have driven in past after drinking, but this time she did not care if she injured herself

(Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did you care that you were driving under the influence? Finding: Followed up on impaired driving - risk for self harm Finding: Reports has had enough of life and did not care if she got hurt/died (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did you drive under the influence in order to hurt yourself? Finding: Reports had not thought about self harm before accident (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you ever wanted to hurt yourself before the accident? Finding: Reports since accident, not sure what to think about what she did (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How do you feel since the accident? Finding: Asked about onset and duration of pain Finding: Reports pain started immediately after accident (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you

Reports accident was last night (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did the car accident happen? Finding: Reports accident was at 10 pm (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did the car accident happen? Finding: Asked about location of pain Finding: Reports pain is in right wrist (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does your wrist hurt? Finding: Asked about aggravating factors of pain Finding: Reports increased pain when bending or twisting (R) wrist (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your pain worse with movement? Finding: Reports increased pain when trying to lift items, even small ones such as a hairbrush (Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your pain worse with movement?

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have shooting pain?

Finding: Asked about severity of pain Finding: Reports current pain level is 2/ (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How would you rate your pain? Finding: Reports pain without medication was 8/ (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How would you rate your pain without medication? Past Medical History Finding: Asked about existing health conditions Finding: Reports no known health problems (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What health problems do you have? Finding: Asked about history of mental health Finding: Denies previous history of mental illness diagnoses (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question:

diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you experienced any depression or sadness? Finding: Reports feeling anxious over the past six months - has not sought treatment/counseling (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you felt anxious? Finding: Reports can not deal with stress of school and life in general (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Is your life stressful? Finding: Reports that she does not care what happens to her anymore (passive suicidal ideation) (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How do you cope with stress? Finding: Followed up on stress issues Finding: Reports stress over parental relationships (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question: How do you get along with your parents? Finding: Reports stress over school (Found) (Available)

Example Question: Why do you think life is not worth living? Finding: Reports not caring that she put herself at risk for injury/death by drinking and driving Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of

diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Why do you think life is not worth living? Finding: Reports feeling like it would be better if she had died in car accident (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Why do you think life is not worth living? Finding: Followed up on passive suicidal ideation Finding: Reports feels unsure of future (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you feel like you are a failure Finding: Reports tired of mother being so critical of her (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What is your relationship with your mother like? Finding: Reports fear of failure and disappointing others (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: