MentalHealth_DavidCarterPart1_DA.docx - Kassandra Maldonado...

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Kassandra Maldonado Mental Health Case: David Carter, Part 1 Documentation Assignments 1. Document findings associated with your screening of Mr. Carter using the AIMS scale. Patient does not have any abnormal involuntary movement. He was slupped in his chair and seemed withdrawn. He is also very tired, he says he sleeps a lot but is always tired, which contributes to him being withdrawan and slupped over in to his chair. 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Mr. Carter just had a few sips of water, he had about 50 ml of water, and 100 ml of urine. MR carter refused to take a shower, and his hari is ucombed and his clothes are dirty. 3. Reconcile Mr. Carter’s medications prior to hospitalization. For the past year Mr Carter has taken olanzapine 10 mg and venlafaxine XR 75 mg daily. It has been checked with what he is currently taking. 4. Identify and document key nursing diagnoses for Mr. Carter.

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