DavidCarterPart1_DA.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. There were no extra movements noted but none of the AIMS tests were conducted yet. 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Unable to perform hygiene care or have proper nutritional intake due to fear of being poisoned. Intake has been minimal as he has only drank/eaten from sealed containers. Output unknown. 3. Reconcile Mr. Carter’s medications prior to hospitalization. Olanzapine 10 mg and venlafaxine XR 75 mg daily 4. Identify and document key nursing diagnoses for Mr. Carter. Disturbed thought process, Disturbed sensory perception: auditory, Impaired social interaction 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this care. Interviewing patient to find out how he’s feeling, his eating habits, energy levels, etc. Mr. Carter frequently diverted his sentences back to a paranoid and fearful state. He seemed irritated by some

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