Mental Health Case Study: David Carter - Part 1 Documentation DA | | Comprehensive Clinical Assessment Summary | Updated 2025 Study Resource

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Mental Health Case Study
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David Carter Part 1
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Mental Health Case: David Carter, Part 1
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Documentation Assignments am




1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
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Using the Aims scale I would say his score is at a level 2 because he is only exhibitng facial movement
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which include frowning and movement of the forhead
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2. Document Mr. Carter’s performance of actvites of daily living and his intake and output for the day.
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Mr. carter has not been very actve. He doesn’t enjoy doing things he use to do. He also has slacked off
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with personal hygiene because his clothes are not well kept and appear to be dirty. He talks about being
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poisoned the whole assessment and has no desires to eat or drink. He only took a few sips of water.
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3. Reconcile Mr. Carter’s medicatons prior to hospitalizaton.
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Medicatons that Mr. Carter currently take are olanzapine 10 mg and venlafaxine XR 75 mg daily. He has
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a 10 year history of schizophrenia and is unstable on medicaton.
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4. Identfy and document key nursing diagnoses for Mr. Carter.
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Disturbed Sensory Percepton: Auditory as evidenced by pt verbalizing that he is hearing voices
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5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this
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care.

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




0:06 You introduced yourself.
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0:34 You washed your hands.
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0:49 You identified the patient.
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1:04 You asked if the patient had any known allergies.
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1:38 You asked the patient: Can you tell me a little bit more about what's going on with
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you today? It was appropriate to ask the patient what was going on with him to get
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an understanding of this.
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1:58 The patient said: They came and got me and forced me into this poison prison. It's
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your fault for keeping us here to rot of poison!\nYou answered: My purpose for being
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here today is to help you and complete your nursing assessment. \nYou used the
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therapeutic technique of giving information. am am am am




2:01 You supported the patient about safe environment.
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From vSim for Nursing | Mental Health. © Wolters Kluwer.
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