Focused_Exam__Alcohol_Use_Disorder___In_Progress_Attempt___Shadow_Health_Mental_Status_Notes

Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p Documentation Review Mental Status Note Student Response Model Documentation Appearance Indirect eye contact, tension and rigidity, clean clothing, and appropriate level of grooming Ms. Adler is a 20-year-old White woman of average heigh average weight. She exhibits indirect eye contact during th examination, and a worried expression. Her posture was tense. When she arrived, Ms. Adler’s clothing was approp to her age and worn appropriately. Appropriate hygiene an grooming. Attitude Generally suspicious, guarded, or evasive Ms. Adler displays no excessive liveliness or intense mannerisms. She has a blunt affect. She is cooperative w the medical staff and forthcoming with information about h current mental state. Speech Expected rate of speech, loud speech volume, and no appreciable issues with articulation Ms. Adler’s speech characteristics display the expected complexity for her age, education level, and general ability Presents no observable articulation problems. Her speech slow, hesitant, and spoken at a low volume. Mood and Affect Stable mood and a balanced affect Ms. Adler expresses a moderate level of anxiety over her current circumstances, stating that the last six months of h life have been stressful, and that she has been increasing anxious. She states that she was overwhelmed. Her responses seem appropriate to the situation, and although is upset, her emotions are within a stable range. Nursing Admitting... Mental Status Note SBAR This study source was downloaded by 100000838987296 from CourseHero.com on 01-31-2023 11:15:55 GMT -06:00 https://www.coursehero.com/collection/60520389/Focused-Exam-Alcohol-Use-Disorder-In-Progress-Attempt-Shadow-Health-Mental-Status-Notespdf/ Student Response Model Documentation Thought Process No presence of thought disturbances Ms. Adler’s pattern of thinking is coherent and logical. She offers relevant information about her circumstances and exhibits a normal continuity of thought. Observed no poten disordered behaviors. Observed no rhyming, clang association, or puns. Thought Content Suicidal ideation Ms. Adler displays passive suicidal ideation and expresse that she does not care if she lives or dies. Ms. Adler does express any active suicidal ideation or plans for ending he life. She says she has never attempted suicide or planned suicide attempt. Ms. Adler seems to be under stress from school and her relationship with her mother. She is deeply distraught over her DUI and the circumstances that broug her to the ER. Perceptual Disturbances No perceptual disturbances Ms. Adler displays no evidence of delusions or observable abnormal tendencies during the exam. There is no eviden hallucinations or false sensory perceptions. Orientation and Level of Consciousness Oriented to person, place, time, and situation A&O x4 Cognition Able to complete the serial sevens series, demonstates abstract thinking with similarity test, remote and immediate memory intact, Normal attention and serial 7s. Normal ability for abstract reasoning. Ms. Adler seems to have a logical train of thou and is capable of understanding why she is here. Her gen intellect appears to be above average. Working memory a episodic memory seem normal. Insight Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment Ms. Adler appears to be unclear in her awareness of her alcohol use. She says she drinks because of stressors like school and her relationship with her family. She describes drinking up to five drinks at a time three or four nights a w and expres