Mental Health Case: Randy Adams/Mental Health Case: Randy Adams Documentation Assignments/Randy Adams Documentation Assignments

Documentation Assignments

1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of

concussion, and symptoms of posttraumatic stress disorder.

Mr. Adams presents with headache and sensitivity to light and noise. His memory has also been

impaired, demonstrated by his ability to recall two of the three words he was asked to

remember. He states that his sleeping has been getting better.

2. Identify and document key nursing diagnoses for Mr. Adams.

- Disturbed senesoy perception related to head injury as evidenced by sensitivity to light and

noise

- Ineffective coping related to traumatic event as evidenced by client stating he “tries not to

think about the accident”

- Anxiety related to traumatic event as evidenced by client exhibit restless behavior, appearing

tense and asking to stand during assessment

3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response

to this care.

Feedback Log

0:00 Patient

0:00 You checked scene safety. It was correct to check scene safety in order to maintain

your own safety.

0:06 You introduced yourself.

0:37 You asked the patient: Is it OK for your wife to be here, while we talk? It was correct

to let the patient give his consent for letting his wife be a part of the interview.