NUR 5305 Tina Jones Subjective Mental Health Shadow Health graded A+
8/28/2019 Mental Health | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/5169784 1/7
Mental Health Results | Turned In
Advanced Health Assessment – Summer 2019, NURS 5305
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Category Scored Items
Experts selected these topics as essential
components of a strong, thorough interview
with this patient.
Patient Data
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 difficulty sleeping began 3 1/2
weeks ago
Subjective Data Collection: 44 of 44 (100.0%) Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Hover To Reveal…
Hover over the Patient Data items
below to reveal important information,
including Pro Tips and Example
Questions.
8/28/2019 Mental Health | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/5169784 2/7
Reports sleep difficulties have been
occurring regularly during past 3 1/2 weeks
Asked about 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 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 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
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