DC Mental Health David Carter Part 1 DA
community mental health (Blessing-Rieman College of Nursing & Health
Sciences)
, Mental Health Case: David Carter, Part 1
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
Using the Aims scale I would say his score is at a level 2 because he is only exhibiting facial movement
which include frowning and movement of the forhead
2. Document Mr. Carter's performance of activities of daily living and his intake and output for the day.
Mr. carter has not been very active. He doesn't enjoy doing things he use to do. He also has slacked
off with personal hygiene because his clothes are not well kept and appear to be dirty. He talks about
being poisoned the whole assessment and has no desires to eat or drink. He only took a few sips of
water.
3. Reconcile Mr. Carter's medications prior to hospitalization.
Medications that Mr. Carter currently take are olanzapine 10 mg and venlafaxine XR 75 mg daily. He
has a 10 year history of schizophrenia and is unstable on medication.
4. Identify and document key nursing diagnoses for Mr. Carter.
Disturbed Sensory Perception: Auditory as evidenced by pt verbalizing that he is hearing voices
5. Referring to your feedback log, document all nursing care provided and Mr. Carter's response to
this care.
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.
0:34 You washed your hands.
0:49 You identified the
patient.
1 :04 You asked if the patient had any known allergies.
1 :38 You asked the patient: Can you tell me a little bit more about what's going on with
you today? It was appropriate to ask the patient what was going on with him to
get an understanding of this.
1 :58 The patient said: They came and got me and forced me into this poison prison.
It's your fault for keeping us here to rot of poison!\nYou answered: My purpose for
being here today is to help you and complete your nursing assessment. \nYou used
the therapeutic technique of giving information.
community mental health (Blessing-Rieman College of Nursing & Health
Sciences)
, Mental Health Case: David Carter, Part 1
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
Using the Aims scale I would say his score is at a level 2 because he is only exhibiting facial movement
which include frowning and movement of the forhead
2. Document Mr. Carter's performance of activities of daily living and his intake and output for the day.
Mr. carter has not been very active. He doesn't enjoy doing things he use to do. He also has slacked
off with personal hygiene because his clothes are not well kept and appear to be dirty. He talks about
being poisoned the whole assessment and has no desires to eat or drink. He only took a few sips of
water.
3. Reconcile Mr. Carter's medications prior to hospitalization.
Medications that Mr. Carter currently take are olanzapine 10 mg and venlafaxine XR 75 mg daily. He
has a 10 year history of schizophrenia and is unstable on medication.
4. Identify and document key nursing diagnoses for Mr. Carter.
Disturbed Sensory Perception: Auditory as evidenced by pt verbalizing that he is hearing voices
5. Referring to your feedback log, document all nursing care provided and Mr. Carter's response to
this care.
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.
0:34 You washed your hands.
0:49 You identified the
patient.
1 :04 You asked if the patient had any known allergies.
1 :38 You asked the patient: Can you tell me a little bit more about what's going on with
you today? It was appropriate to ask the patient what was going on with him to
get an understanding of this.
1 :58 The patient said: They came and got me and forced me into this poison prison.
It's your fault for keeping us here to rot of poison!\nYou answered: My purpose for
being here today is to help you and complete your nursing assessment. \nYou used
the therapeutic technique of giving information.
