David Carter part 1.docx - Mental Health Case David Carter...

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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 The patient is disheveled and withdrawn.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. 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Mr. Carter has refused to eat today due to the fact that he believes the food is being poisoned. He agreed to take his medications. 3. Reconcile Mr. Carter’s medications prior to hospitalization. Olanzapine 10 mg and Venlafaxine 75 mg daily 4. Identify and document key nursing diagnoses for Mr. Carter.

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