NUR 5305 Tina Jones Subjective Mental Health Shadow Health
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Subjective Data Collection
Objective Data Collection
Education & Empathy Documentation
Subjective Data Collection: 44 of 44 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Established chief complaint Reports difficulty sleeping and “feeling nervous”
Reports seeking treatment because she has an upcoming exam and feels “too foggy to study”
Reports excessive worry and “racing thoughts” before bed
History of Present Illness
Asked about onset and duration of symptoms
Reports of difficulty sleeping began 3 1/2 weeks ago
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Reports sleep difficulties have been occurring regularly during the past 3 1/2 weeks
Asked about the frequency of symptoms Reports difficulty sleeping at least four or
five times a week
Asked about aggravating factors Reports sleeping becomes more difficult
when she can not redirect her thoughts from the things she is worried about
Denies naps during the day
Reports drinking caffeine to stay alert Reports stopping caffeine use after 4 P.M. Denies alcohol use before bed
Denies drug use before bed Reports respiratory problems are
controlled and not interfering with sleep
Asked about relieving factors Reports sleeping more easily if she can distract herself from her “racing thoughts” Reports no exercise
Asked about the impact of sleeping problems on daily living
Reports feeling tired and “out of it” most of the time during the day due to lack of sleep
Reports no increased chance of drifting off during the day despite lack of sleep
Followed up about patient’s experience feeling “out of it”
Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp”
Asked about anxiety symptoms Reports feelings of anxiety as “thoughts
she can’t turn off” and “being on edge”
Reports worry about the future, but no sense of impending doom
Reports no panic attacks
Reports difficulty concentrating due to fatigue from lack of sleep
Reports only restlessness occurs just before bed
Reports slight irritability due to fatigue
Asked about the impact of anxiety on daily living
Reports stress only interferes with daily life because it interrupts her sleep
Reports stress does not prevent her from completing her usual activities
Asked about sleep quality Reports falling asleep often takes more than an hour
Reports waking up two or three times during the night for “at least ten minutes”
Reports waking in the morning feeling “out of it” and not rested
Asked about sleep habits Reports going to bed “around midnight,” but feeling “too nervous” to sleep
Reports actually falling asleep at 2 or 3 AM
Reports reading before bed
Reports no screen use (television or computer) before bed
Reports average wake time of 8 AM Reports sleeping an average of 4 or 5
hours a night
Reports sleeping alone in a quiet room
Asked about stress causes Reports feeling stressed about studying and “the future”
Reports CPA professional qualifying exam in one month
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