Use the case scenario to complete a health history andmental Health assessment. Information about past health history canbe made up
CASE SCENARIO
You are a nurse on an inpatient psychiatric unit. J.M.,a 23-year-old woman, was Respond to at least one other studentadmitted to the psychiatric unit last night after assessment andtreatment at a local hospital emergency department for “blackingout at school.” She has been given a preliminary diagnosis ofanorexia nervosa. As you begin to assess her, you notice that shehas very loose clothing, she is wrapped in a blanket, and herextremities are very thin. She tells you, “I don’t know why I’mhere. They’re making a big deal about nothing.” She appears to beextremely thin and pale, with dry and brittle hair, which is verythin and patchy, and she constantly complains about being cold. Asyou ask questions pertaining to weight and nutrition, she becomesdefensive and vague, but she does admit to losing “some” weightafter an appendectomy 2 years ago. She tells you that she used tobe fat, but after her surgery she didn’t feel like eating andeverybody started commenting on how good she was beginning to look,so she just quit eating for a while. She informs you that she iseating lots now, even though everyone keeps “bugging me about myweight and how much I eat.” She eventually admits to a weight lossof “about 40 pounds and I’m still fat.
● Health History – complete health history with subjectheadings as below in an organized, coherent and systematic manner,include which day of admission/post operative day did you care forthis patient
o Source of history
o Reason for seeking care (chiefcomplaint)
o History of present illness(HPI)
o Past health (medical, surgical,psychosocial)
o Family history
o Review of systems (ROS): complete ROS with subjectheadings as below in an organized, coherent and systematic manner,should include all systems indicated below with at least threenegatives and/or positives
✔General/Constitutional
✔Skin (Integument), Hair
✔Head, Eyes, Ears, Nose, Oral Cavity, Throat(HEENOT)
✔Neck
✔Breast and Axilla
✔Respiratory
✔Cardiovascular
✔Peripheral Vascular
✔Gastrointestinal
✔Urinary
✔Male and Female Genital
✔Sexual
✔Musculoskeletal
✔Neurologic
✔Hematologic
✔Endocrine
o Functional assessment (lifestyle): complete functionalassessment with subject headings as below in an organized, coherentand systematic manner ✔Education, financial status (income adequatefor lifestyle)
✔Activity/exercise: ADLs/IADLs, leisureactivities
✔Sleep/rest
✔Nutrition/elimination: height/weight, 24 hourrecall
✔Spiritual resources
✔Interpersonal relationships/resources (may screen forintimate partner violence) ✔Coping and stressmanagement
✔Personal habits: tobacco, alcohol (CAGE questionnaire),caffeine, illegal drug use ✔Environmental hazards (housing andneighborhood)
● Mental Status Assessment – Use criteriaabove.
