DC Mental Health David Carter Part 1 DA PDF

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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. Using the Aims scale I would say his score is at a level 2 because he is only exhibiting facial movement which include frowning and movement of the forhead 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. Mr. carter has not been very active. He doesn’t enjoy doing things he use to do. He also has slacked off with personal hygiene because his clothes are not well kept and appear to be dirty. He talks about being poisoned the whole assessment and has no desires to eat or drink. He only took a few sips of water. 3. Reconcile Mr. Carter’s medications prior to hospitalization. Medications that Mr. Carter currently take are olanzapine 10 mg and venlafaxine XR 75 mg daily. He has a 10 year history of schizophrenia and is unstable on medication. 4. Identify and document key nursing diagnoses for Mr. Carter. Disturbed Sensory Perception: Auditory as evidenced by pt verbalizing that he is hearing voices 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this care. 0: 00

Youcheck edsc enesaf et y .I twasc or r ectt ocheckscenesaf et yi nor dert omai nt ai n y ourownsaf et y .

0: 06

Youi nt r oducedy our s el f .

0: 34

Youwas hedy ourhands .

0: 49

Youi dent i fi edt hepat i ent .

1: 04

Youask edi ft hepat i enthadanyknownal l er gi es.

1: 38

Youask edt hepat i ent :Cany out el l meal i t t l ebi tmor eaboutwhat ' sgoi ngonwi t h y out oday?I twasappr opr i at et oaskt hepat i entwhatwasgoi ngonwi t hhi mt oget anunder st andi ngoft hi s .

1: 58

Thepat i entsai d:Theycameandgotmeandf or cedmei nt ot hi spoi sonpr i s on.I t ' s y ourf aul tf ork eepi ngusher et or otofpoi son! \ nYouans wer ed:Mypur posef orbei ng her et odayi st ohel py ouandcompl et ey ournur si ngasses sment .\ nYouusedt he t her apeut i ct echni queofgi vi ngi nf or mat i on.

From vSim for Nursing | Mental Health. © Wolters Kluwer.

2: 01

Yousuppor t edt hepat i entaboutsaf eenv i r onment .

2: 12

Youask edt hepat i ent :Ov ert hepasty ear ,whendi dy ouf eely ourbest ?I twas appr opr i at et oaskt hepat i entaboutwhenhef el thi sbest .

2: 27

Thepat i entsai d:Ar ey ouoneoft hoses pi est oo?Theot heronest r i edt opoi sonme wi t ht hei rpoi sont r ay s. \ nYouanswer ed:Mr .Car t er .Iam y ournur se.I ' m her et ot ake car eofy out oday .\ nYouusedt het her apeut i ct ec hni queofgi vi ngi nf or mat i on.

2: 36

Youask edt hepat i ent :Doy ouhav eanypai n?Thepat i entsai d:No,Idon' thaveany pai n.

2: 54

Youask edt hepat i ent :Hav ey ouhadanychangesi ny ourappet i t eov ert hepas t mont h?

3: 08

Thepat i entsai d:I ' m notgoi ngt oeat ;noonecanmak emeeatpoi s on. \ nYou ans wer ed:Hav ey ouhadsi mi l arexper i ences ?\ nYouusedt het her apeut i ct echni que ofencour agi ngcompar i son.

3: 17

Yousuppor t edt hepat i entaboutr eal i t yofvoi ces .

3: 24

Yousuppor t edt hepat i entabouthear i ngvoi ces .

3: 40

Youask edt hepat i ent :Howmanymeal sdoy oueateachday ?

3: 55

Thepat i entsai d:I ' m notgoi ngt ol ett hem hackme.I ' m noteat i nganyoft hehack poi son. \ nYouanswer ed:Youment i onedpoi son.Hav ey ouhadsi mi l arex per i encesi n t hepast ?\ nYouusedt het her apeut i ct echni queofencour agi ngcompar i s on.

4: 00

Yousuppor t edt hepat i entaboutf oodanddr i nk .

4: 15

Youask edt hepat i ent :Hav ey oul os torgai nedwei ghtov ert hepastmont h?The pat i entsai d:Gai nedabout20pounds .St ar t edaboutay earagowhent heygav eme newmeds.

4: 29

Youask edt hepat i ent :Tel lmeaboutanychangesy ouhav ehadi nyours l eepov er t hepastf ewweek s ?Thepat i ents ai d:Yeah. . . .I ' v ebeensl eepi ngal otl at el ybutI ' m s t i l lt i r ed. . . .I ' mt i r edal l t het i me.

4: 42

Youask edt hepat i ent :Appr oxi mat el yhowmanyhour sofsl eepdoy ougeteach ni ght ?Thepat i entsai d:Lat el yabout12hour sandIam st i l l t i r ed.

4: 53

Youask edt hepat i ent :Doy ouhav eener gyt odot heact i v i t i est hatgi v ey ou enj oy ment ?Thepat i entsai d:No,notr eal l y .

5: 28

Youask edt hepat i ent :Iwoul dl i k et oasky ouaser i esofquest i onsabouthowy ou ar ef eel i ngt ohel pmebet t erunder s t andhowt oget herwecanst ar tt opl any ourcar e. Thes ear eques t i onsIas kal l oft hepat i ent sIsee.MayIasky out heseques t i ons ? Thepat i entsai d:Iguess .

5: 52

Youask edt hepat i ent :Doy ouf eel al er tt oanswerques t i ons ?

From vSim for Nursing | Mental Health. © Wolters Kluwer.

6: 05

Thepat i entsai d:Thespi est al kaboutmeal l t het i me.Icanheart hem t al ki ngabout menow. \ nYouanswer ed:Iunder s t andy oudo,butIdon' thearany oneel sei nt he r oom.\ nYouusedt het her apeut i ct echni queofpr esent i ngr eal i t y .

6: 10

Youask edt hepat i ent :Pl easet el l mey ourname.Thepat i ents ai d:Davi dCar t er .

6: 15

Youask edt hepat i ent :Cany out el l mewher ewear e?Thepat i entsai d:I st hi sa hospi t al ?

6: 21

Youask edt hepat i ent :Pl easet el l mewhatt oday ' sdat ei s .Thepat i entsai d:( No r esponse)

6: 43

Youask edt hepat i ent :Howwoul dy oudesc r i bey ourmood?

6: 55

Thepat i entsai d:I ' m dr owni ng. \ nYouanswer ed:Ar ey ousugges t i ngt haty ouf eel over whel med?\ nYouus edt het her apeut i ct echni queoft r ans l at i ngi nt of eel i ngs .

7: 05

Youask edt hepat i ent :Hav ey oul os ti nt er es ti nact i vi t i est haty ouonceenj oy ed?The pat i entsai d:Iam t oobusywi t ht hevoi cest odoanyt hi ng.

7: 13

Youask edt hepat i ent :Nameanact i vi t yt haty ouenj oy .Thepat i ents ai d:Idon' t know.

7: 19

Youask edt hepat i ent :Cany ounamet hel astfi v eAmer i canpr esi dent sst ar t i ngwi t h Bar ac kObamaandgoi ngback ?Thepat i ents ai d:Bar ackObama,Geor geW.Bus h, Bi l lCl i nt on,Geor geH.W.Bush,Ronal dReagan.

7: 37

Youask edt hepat i ent :Cany out el l mewhaty ouat ef orbr eakf ast ?Thepat i entsai d: Idi dn' teatbec auseoft hepoi son.

7: 53

Youeducat edaboutdai l yl i vi ng.

8: 11

Youask edt hepat i ent :Doy ouhav eanyt hought sorwi shest ohar m orki l ly our s el f ?

8: 22

Thepat i entsai d:Ican' tdot hi sany mor e. \ nYouanswer ed:Ar ey ouconsi der i ng hur t i ngyour s el forsomeoneel se ?\ nYouusedt het her apeut i ct echni queofseek i ng i nf or mat i on.

8: 28

Youask edt hepat i ent :Doy ouhav eanyt hought sorwi shest ohar m any bodyel s e? Thepat i entsai d:Thev oi cest el lmeIhav et ost opt hespi eswhoar el i st eni ngt omy t hought sandpoi s oni ngmyf ood.

8: 42

Youask edt hepat i ent :Cany out el l mewhatadesi r edout comeoft r eat mentwoul d bef ory ou?

8: 56

Thepat i entsai d:Ihavet ogetoutofal l t hi spoi son.I t ' sl oudandal lar oundme! \ nYou ans wer ed:Ar ey out r y i ngt os ayy ouar ehear i ngv oi cesnow?\ nYouusedt he t her apeut i ct echni queofv er bal i zi ngt hei mpl i ed.

9: 02

Youask edt hepat i ent :Howdoy ouunder s t andy ourpr obl ems ?

From vSim for Nursing | Mental Health. © Wolters Kluwer.

9: 17

Thepat i entsai d:Theygott omymom;t heywi l l gett oy out oo.Youneedt ousea smegl eory ouwi l l endupl i k et hem. \ nYouanswer ed:Idon' tunder s t andwhaty ou meanbyt hat .Woul dy ouex pl ai ni tt ome ?\ nYouusedt het her apeut i ct echni queof seek i ngi nf or mat i on.

9: 27

Youask edt hepat i ent :Doy ouev erseeorheart hi ngst hatot herpeopl edonot ?

9: 41

Thepat i entsai d:Noonebel i ev esme. \ nYouanswer ed:Tel l memor eaboutt hat . \ nYouusedt het her apeut i ct echni queofex pl or i ng.

9: 45

Youask edt hepat i ent :Doy oufindt haty ouwor r ymor et hanot her s ?

9: 48

Youask edt hepat i ent :Ar ey ouf r i ght enedofany t hi ng?

9: 58

Thepat i entsai d:It r i edt owar nev er yone. \ nYouanswer ed:Yout r i edt owar n ev er y one ?\ nYouusedt het her apeut i ct echni queofr est at i ng.

10: 03 Youask edt hepat i ent :Ar ey ouf r i ght enedofany t hi ng? 10: 17 Thepat i entsai d:Al l ofy ouar epar tofi t ,ar en' ty ou?Youar eal l i ni tt oget her ! \ nYou ans wer ed:Inot i cet haty ouappearuncomf or t abl e.\ nYouusedt het her apeut i c t echni queofmaki ngobser v at i ons . 10: 30 Yousuppor t edt hepat i entaboutget t i nghel pf r om t heheal t hcar et eam. 13: 59 Yousubmi t t edt heMent al St at usEx ami nat i onf or m.Thef or mi scor r ect l ycompl et ed. 14: 20 Youeducat edaboutt hepsy c hi at r i cdi agnos i s . Youshoul dhaveask edaboutt hepat i ent ' sener gyl ev el t odonor mal act i vi t i es. 14: 41 Youeducat edaboutmedi cat i ons . 15: 11 Youeducat edaboutdai l yl i vi ng. 15: 28 Youeducat edaboutdi s char ge. 15: 50 Youcal l edt hechar genur s e.Thi si sr eas onabl eatt hi spoi nt . 16: 09 Youadmi ni st er edl or az epam.

6. Document your handoff report in the SBAR format to communicate the care plan for Mr. Carter to the nurse on the next shift. David Carter, a 28-year-old male, was admitted today after he became violent with his mother and threw a table at her when she asked him to take his medications. She then called the police, who brought him to the emergency room. David has a 10-year history of schizophrenia and has previously been stable on his medications. However, recently he has become more isolated, not going out and always sitting at his computer, and his mother reports that he has been posting some pretty weird updates online. Lately he has

From vSim for Nursing | Mental Health. © Wolters Kluwer.

also been talking about his food being poisoned, so his mother suspects that he has stopped taking his medications, probably because he believes they are responsible for his weight gain. The current medications, which he has been taking for the last year, include olanzapine 10 mg and venlafaxine XR 75 mg daily. He has paranoid delusions, believing that people are listening to his thoughts, and he has auditory hallucinations telling him that he should not eat the hospital food because it is poisoned. Mental status examination was completed. His speech is tangential with some evidence of neologisms, and it is difficult to carry on a conversation with him. He has refused a shower and has a disheveled, dirty appearance. His vital signs, as follow, are stable: temperature, 37.2°C (99°F); heart rate, 90 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/84; and blood oxygen saturation, 96%. I Recommend orient him to reality, offer food, and find ways to encourage him to eat it.

From vSim for Nursing | Mental Health. © Wolters Kluwer....