정신간호학 Randy Adams vsim(브이심) reflection document

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"정신간호학 Randy Adams vsim(브이심) reflection document"에 대한 내용입니다.

목차

I. 내용
1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder.
2. Identify and document key nursing diagnoses for Mr. Adams.
3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care.
4. Document instances of therapeutic communication and Mr. Adams’ response to this intervention.
5. Document the patient teaching related to posttraumatic stress disorder and concussion, as well as medications, that you provided to Mr. Adams and his wife before discharge.
6. Document your handoff report in the SBAR format to communicate Mr. Adams’ future needs.

II. 평가
1. Opening Questions
1) How did the simulated experience of Randy Adams’ make you feel?
2) Talk about what went well in the scenario.
3) Reflecting on Randy Adams’ case, were there any actions you would do differently? If so, what were these actions and why?
2. Scenario Analysis Questions*
1) PCC/S What could occur if Randy Adams kept taking his sumatriptan succinate?
2) PCC/I Discuss the types of support groups and resources that would be beneficial to Randy Adams and his family.
3) I What benefit services are available for veterans with PTSD?
4) PCC What discharge teaching needs to be given to Randy Adams’ wife related to his care?
3. Concluding Questions
1) How would you apply the skills and knowledge gained in the Randy Adams case to an actual patient situation in different acute care units (emergency room, intensive care unit, obstetrics unit, etc.)?

본문내용

1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder.
-acute concussion scale
physical :　두통, 광선민감성, 소음민감성
cognitive :　집중하기 어려움, 기억하기 어려움
emotional : 자극적, 감정적, 신경질적임
sleep : 평소보다 잠을 덜잠
exertion : 인지적 활동
overall rating : 1점 총 9점

-primary care-post traumatic stress disorder screen
원하지 않을 때도 악몽을 경험하거나 생각한다 (+)
그런 것을 상기시키는 것을 피하려고 노력한다. (+)
지속적으로 보호하고 쉽게 놀라는지 ? (+)
다른 사람, 활동, 주변으로부터 분리되거나 무감각하다고 느껴지는지 ? (+)

-mini-cog (치매선별검사)
각 단어가 자발적으로 기억나는지 ? 2점/0-3점
시계를 그려보세요. : 2점/0-2점

2. Identify and document key nursing diagnoses for Mr. Adams.
외상 후 스트레스 장애와 관련된 수면 장애
SD :　“자려고 누우면 이상한 소리가 들려요”,, “잠 자는 시간이 줄었어요. ”
OD : 불안한 모습을 보임.
3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care.
병실인 안전한지 확인함. 간호사 본인을 소개함 환자의 식별번호를 확인하고 손을 씻음. 대상자에게 대화하는 동안 아내가 있어도 되냐고 물었고 대상자는 보호자가 떠나길 원치 않아함. 활력징후를 측정함.

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