David carter part one documentation assignment PDF

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David carter part one documentation assignment lippincott the point virtual simulation assignment psych nursing virtual simulation...

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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. Facial movements (0)- none noted Extremities (2)- patient was restless during the interview and showed mild abnormal movements of his upper limbs Trunk movements (0)- none noted Global judgements (1)- patient was aware of his movements but was not distressed about them as they were attributed to his auditory hallucinations Dental status- unknown- was not able to assess Overall score= 3 possible evidence of dyskinesia 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Unknown- but an example documentation would be: Patient did not bathe. This RN encouraged the patient to bathe and provided toiletries and towels, but the patient still refused. Patient did not provide oral care. Patient was able to secure his hair in a bun for the day. Patient did not eat breakfast, ate 30% of his lunch, and 30% of his dinner. This RN encouraged him to eat at all 3 meals and in between meals offered the patient snacks. Patient drank 1.5 L of water this shift, but required constant encouragement and reminders to do so. 3. Reconcile Mr. Carter’s medications prior to hospitalization. Prior to hospitalization the patient was taking Olanzapine 10mg PO QD and venlafaxine XR 75mg PO QD. These medications are appropriate for the treatment of schizophrenia and do not have any negative interactions with each other. The dosages and route of administration are correct. 4. Identify and document key nursing diagnoses for Mr. Carter. Imbalanced nutrition less than body requirements Disturbed thought process Impaired social interaction 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this care. I checked scene safety, introduced myself, washed my hands, identified the patient, asked about

allergies, performed medication reconciliation, and took the patient’s vital signs. I then assessed his appearance, attention, motor activity, speech, and thought processes. I then performed the verbal portion of the mental status exam. I found the patient was disheveled and withdrawn. There was evidence he was lacking in self care/performing ADLs. He was talking to himself. He had poor eye contact. He is appropriately dressed. He had difficulty focusing on our conversation. He appeared restless with purposeful coordinated movements. He has slow verbal responses and neologisms. His thought process was loose and tangential. He was not oriented to the date. He denied SI, HI. He reported auditory hallucinations. His hallucinations and delusions include that spies are watching him, listening to his thoughts, and poisoning his food. He appeared frustrated that staff and his mother did not believe his hallucinations and delusions were real. He reported sleeping more than usual but still being tired all the time. He reported gaining about 20 pounds since he started his medications a year ago. I used therapeutic communication techniques throughout our conversation (see below). I then supported the patient a safe environment, hearing voices, the reality of the voices, getting help from the healthcare team, and food and drink. I provided patient education regarding discharge, daily living, medication, and about his psychiatric diagnosis. I then called the provider and the charge nurse. Therapeutic communications: You asked the patient: Do you feel alert to answer questions? The patient said: The spies talk about me all the time. I can hear them talking about me now. You answered: I understand you do, but I don't hear anyone else in the room. You used the therapeutic technique of presenting reality. You asked the patient: How would you describe your mood? The patient said: I'm drowning. You answered: Are you suggesting that you feel overwhelmed? You used the therapeutic technique of translating into feelings. You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? The patient said: I can't do this anymore. You answered: Are you considering hurting yourself or someone else? You used the therapeutic technique of seeking information.

You asked the patient: Can you tell me what a desired outcome of treatment would be for you? The patient said: I have to get out of all this poison. It's loud and all around me! You answered: Are you trying to say you are hearing voices now? You used the therapeutic technique of verbalizing the implied.

You asked the patient: How do you understand your problems? The patient said: They got to my mom; they will get to you too. You need to use a smegle or you will end up like them. You answered: I don't understand what you mean by that. Would you explain it to me? You used the therapeutic technique of seeking information. You asked the patient: Do you ever see or hear things that other people do not? The patient said: No one believes me. You answered: Tell me more about that. You used the therapeutic technique of exploring. You asked the patient: Do you find that you worry more than others? The patient said: I tried to warn everyone. You answered: You tried to warn everyone? You used the therapeutic technique of restating. You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with him to get an understanding of this. The patient said: They came and got me and forced me into this poison prison. It's your fault for keeping us here to rot of poison! You answered: My purpose for being here today is to help you and complete your nursing assessment. You used the therapeutic technique of giving information. You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when he felt his best. The patient said: Are you one of those spies too? The other ones tried to poison me with their poison trays. You answered: Mr. Carter. I am your nurse. I'm here to take care of you today. You used the therapeutic technique of giving information. You asked the patient: Have you had any changes in your appetite over the past month? The patient said: I'm not going to eat; no one can make me eat poison. You answered: Have you had similar experiences? You used the therapeutic technique of encouraging comparison. 6. Document your handoff report in the SBAR format to communicate the care plan for Mr. Carter to the nurse on the next shift. ISBAR

Introduction Your name, position, unit

RN, Mental health unit

Situation Patient’s name, age, reason for visit

David Carter is a 28yo male admitted to the unit after a violent encounter with his mother when he refused to take medications

Background Patient’s primary diagnosis, date of admission, current orders for patient

Patient was admitted 2 hrs ago, has a 10 year history of schizophrenia. Recently he has had an increase in tangential thought, delusions, disorganized behavior, poor self care. Currently taking Olanzapine 10mg PO QD and Venlafaxine XR 75mg PO QD for one year.

Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

BP: 134/84 HR: 90 Temp: 98.6 SPO2:96 RR: 16 Height:178cm Weight: 95kg Today I completed a mental status examination. I found the patient was disheveled and withdrawn. He was talking to himself. He had poor eye contact. He is appropriately dressed. He had difficulty focusing on our conversation. He appeared restless with purposeful coordinated movements. He has slow verbal responses and neologisms. His thought process was loose and tangential. He was not oriented to the date. He denied SI, HI. He reported auditory hallucinations. His hallucinations and delusions include that spies are watching him, listening to his thoughts, and poisoning his food. He appeared frustrated that staff and his mother did not believe his hallucinations and delusions were real. He reported sleeping more than usual but still being tired all the time. I reoriented the patient back to reality as appropriate throughout our conversation I also encouraged the patient to eat

Recommendation Any orders or recommendations you have for this patient

I recommend that this patient continue his inpatient treatment until stable. Continue to administer medications as prescribed and monitor his behavior. Encourage him to eat and offer snacks frequently. Provide him with food that comes in sealed packages. Reorient him back to reality and redirect his behaviors as needed. Encourage or assist with ADLs...