David carter documentation.doc - Mental Health Case David...

This preview shows page 1 - 2 out of 2 pages.

Mental Health Case: David Carter, Part 1 Documentation Assignments 1. Document findings associated with your screening of Mr. Carter using the AIMS scale. His speech is tangential with some evidence of neologisms. He has delusions and worries and anhedonia. Orientation and cognitive fuction is impared. Appropraitelt dressed for weather. 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Mr. carter refused to eat anything today, because he believes that the food is poisoned. Lacked performing activites of daily living exience by patient lack of self neglect and dirty clothes 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. Impaired Verbal Communication Impaired Social Interaction Disturbed Sensory Perception: Auditory/Visual Disturbed Thought Process 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture