Jenae Young
10/27/2020
Mental Health Case: David Carter, Part 1
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day.
3. Reconcile Mr. Carter’s medications prior to hospitalization.
4. Identify and document key nursing diagnoses for Mr. Carter.
5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this
care.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
was
correct to
check
scene
safety in
order to
maintain
your own
safety.
0:05
You introduced yourself.
0:27
You washed your hands.
0:34
You identified the patient.
1:01
You asked if the patient had any known allergies.
1:07
You performed medication reconciliation.
1:26
You assessed the respiration.
1:36
You checked the pulse oximetry.
1:54
You checked the radial pulse.
2:06
You measured the blood pressure.
2:22
You measured the temperature.
2:37
You auscultated the lung sounds.
2:48
You auscultated the heart sounds.
3:03
You observed the appearance.
3:26
You checked the patient's skin.
3:45
You assessed the attention.
3:57
You observed the motor activity.
4:07
You assessed the speech.
4:14
You assessed the thought processes.
4:36
You asked the patient: What is your full name? The patient said: My name
is David Carter.
4:42
You asked the patient: Have you taken your medication?
From vSim for Nursing | Mental Health. © Wolters Kluwer.
4:54
The patient said: I'm not going to eat; no one can make me eat
poison.\nYou answered: Have you had similar experiences? \nYou used the
therapeutic technique of encouraging comparison.
