Mental Health Case David Carter, Part 1

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 You checked scene safety. It was correct to check scene safety in order to maintain your own safety. 0:06 You introduced yourself. 0:34 You washed your hands. 0:49 You identified the patient. 1:04 You asked if the patient had any known allergies. 1:38 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. 1:58 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!\nYou answered: My purpose for being here today is to help you and complete your nursing assessment. \nYou used the therapeutic technique of giving information. 2:01 You supported the patient about safe environment. 2:12 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. 2:27 The patient said: Are you one of those spies too? The other ones tried to poison me with their poison trays.\nYou answered: Mr. Carter. I am your nurse. I'm here to take care of you today. \nYou used the therapeutic technique of giving information. 2:36 You asked the patient: Do you have any pain? The patient said: No, I don't have any pain. 2:54 You asked the patient: Have you had any changes in your appetite over the past month? 3:08 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. 3:17 You supported the patient about reality of voices. 3:24 You supported the patient about hearing voices. 3:40 You asked the patient: How many meals do you eat each day? 3:55 The patient said: I'm not going to let them hack me. I'm not eating any of the hack poison.\nYou answered: You mentioned poison. Have you had similar experiences in the past? \nYou used the therapeutic technique of encouraging comparison. 4:00 You supported the patient about food and drink. 4:15 You asked the patient: Have you lost or gained weight over the past month? The patient said: Gained about 20 pounds. Started about a year ago when they gave me new meds. 4:29 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: Yeah.... I've been sleeping a lot lately but I'm still tired.... I'm tired all the time. 4:42 You asked the patient: Approximately how many hours of sleep do you get each night? The patient said: Lately about 12 hours and I am still tired. 4:53 You asked the patient: Do you have energy to do the activities that give you enjoyment? The patient said: No, not really. 5:28 You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see. May I ask you these questions? The patient said: I guess. 5:52 You asked the patient: Do you feel alert to answer questions? 6:05 The patient said: The spies talk about me all the time. I can hear them talking about me now.\nYou answered: I understand you do, but I don't hear anyone else in the room. \nYou used the therapeutic technique of presenting reality. 6:10 You asked the patient: Please tell me your name. The patient said: David Carter. 6:15 You asked the patient: Can you tell me where we are? The patient said: Is this a hospital? 6:21 You asked the patient: Please tell me what today's date is. The patient said: (No response) 6:43 You asked the patient: How would you describe your mood? 6:55 The patient said: I'm drowning.\nYou answered: Are you suggesting that you feel overwhelmed? \nYou used the therapeutic technique of translating into feelings. 7:05 You asked the patient: Have you lost interest in activities that you once enjoyed? The patient said: I am too busy with the voices to do anything. 7:13 You asked the patient: Name an activity that you enjoy. The patient said: I don't know. 7:19 You asked the patient: Can you name the last five American presidents starting with Barack Obama and going back? The patient said: Barack Obama, George W. Bush, Bill Clinton, George H. W. Bush, Ronald Reagan. 7:37 You asked the patient: Can you tell me what you ate for breakfast? The patient said: I didn't eat because of the poison. 7:53 You educated about daily living. 8:11 You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? 8:22 The patient said: I can't do this anymore.\nYou answered: Are you considering hurting yourself or someone else? \nYou used the therapeutic technique of seeking information. 8:28 You asked the patient: Do you have any thoughts or wishes to harm anybody else? The patient said: The voices tell me I have to stop the spies who are listening to my thoughts and poisoning my food. 8:42 You asked the patient: Can you tell me what a desired outcome of treatment would be for you? 8:56 The patient said: I have to get out of all this poison. It's loud and all around me!\nYou answered: Are you trying to say you are hearing voices now? \nYou used the therapeutic technique of verbalizing the implied. 9:02 You asked the patient: How do you understand your problems? 9:17 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.\nYou answered: I don't understand what you mean by that. Would you explain it to me? \nYou used the therapeutic technique of seeking information. 9:27 You asked the patient: Do you ever see or hear things that other people do not? 9:41 The patient said: No one believes me.\nYou answered: Tell me more about that. \ nYou used the therapeutic technique of exploring. 9:45 You asked the patient: Do you find that you worry more than others? 9:48 You asked the patient: Are you frightened of anything? 9:58 The patient said: I tried to warn everyone.\nYou answered: You tried to warn everyone? \nYou used the therapeutic technique of restating. 10:03 You asked the patient: Are you frightened of anything? 10:17 The patient said: All of you are part of it, aren't you? You are all in it together!\nYou answered: I notice that you appear uncomfortable. \nYou used the therapeutic technique of making observations. 10:30 You supported the patient about getting help from the health care team. 13:59 You submitted the Mental Status Examination form. The form is correctly completed. 14:20 You educated about the psychiatric diagnosis. You should have asked about the patient's energy level to do normal activities. 14:41 You educated about medications. 15:11 You educated about daily living. 15:28 You educated about discharge. 15:50 You called the charge nurse. This is reasonable at this point. 16:09 You administered lorazepam. 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 sitÝng at his computer, and his mother reports that he has been posting some pretty weird updates online. Lately he has 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 difÏcult 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.