Mental Health Case: David Carter, Part 1
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
The patient is disheveled and withdrawn. He is sitting, slouched, looking downward, with
only brief moments of eye contact. The patient engages with apprehension. He has difficulty
focusing on the conversation due to auditory hallucinations. The patient is restless, and his
movements are purposeful and coordinated. There is no evidence of tics, tremors, or
unusual movements.
m
2. Document Mr. Carter’s performance of activities of daily living and his intake and output
er as
for the day.
co
eH w
Mr. Carter has refused to eat today due to the fact that he believes the food is being
o.
poisoned. He agreed to take his medications.
rs e
ou urc
3. Reconcile Mr. Carter’s medications prior to hospitalization.
Olanzapine 10 mg and Venlafaxine 75 mg daily
o
aC s
4. Identify and document key nursing diagnoses for Mr. Carter.
vi y re
Imbalanced nutrition r/t auditory hallucinations as evidenced by Pt verbalizing the food is
poisoned, and refusing to eat.
ed d
5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s
ar stu
response to this care.
-Checked the scene for safety.
is
-Identified the patient and introduced self.
Th
-Asked the patient general questions about well-being, sleep patterns, appetite, and energy
levels.
sh
-Performed a mental status assessment.
-Submitted mental status assessment to charge nurse.
-Supported patient in times of agitation, worry, and fright.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
This study source was downloaded by 100000826167209 from CourseHero.com on 06-09-2021 04:51:18 GMT -05:00
https://www.coursehero.com/file/43502320/David-Carter-part-1docx/
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
The patient is disheveled and withdrawn. He is sitting, slouched, looking downward, with
only brief moments of eye contact. The patient engages with apprehension. He has difficulty
focusing on the conversation due to auditory hallucinations. The patient is restless, and his
movements are purposeful and coordinated. There is no evidence of tics, tremors, or
unusual movements.
m
2. Document Mr. Carter’s performance of activities of daily living and his intake and output
er as
for the day.
co
eH w
Mr. Carter has refused to eat today due to the fact that he believes the food is being
o.
poisoned. He agreed to take his medications.
rs e
ou urc
3. Reconcile Mr. Carter’s medications prior to hospitalization.
Olanzapine 10 mg and Venlafaxine 75 mg daily
o
aC s
4. Identify and document key nursing diagnoses for Mr. Carter.
vi y re
Imbalanced nutrition r/t auditory hallucinations as evidenced by Pt verbalizing the food is
poisoned, and refusing to eat.
ed d
5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s
ar stu
response to this care.
-Checked the scene for safety.
is
-Identified the patient and introduced self.
Th
-Asked the patient general questions about well-being, sleep patterns, appetite, and energy
levels.
sh
-Performed a mental status assessment.
-Submitted mental status assessment to charge nurse.
-Supported patient in times of agitation, worry, and fright.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
This study source was downloaded by 100000826167209 from CourseHero.com on 06-09-2021 04:51:18 GMT -05:00
https://www.coursehero.com/file/43502320/David-Carter-part-1docx/
