Mental Health Case: David Carter, Part 1

Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.

The patient is disheveled and withdrawn. He is sitting, slouched, looking downward, with
only brief moments of eye contact. The patient engages with apprehension. He has difficulty
focusing on the conversation due to auditory hallucinations. The patient is restless, and his
movements are purposeful and coordinated. There is no evidence of tics, tremors, or
unusual movements.

2. Document Mr. Carter’s performance of ac@vi@es of daily living and his intake and output for the day.

Mr. Carter has refused to eat today due to the fact that he believes the food is being
poisoned. He agreed to take his medications.
3. Reconcile Mr. Carter’s medica@ons prior to hospitaliza@on.

4. Iden@fy and document key nursing diagnoses for Mr. Carter.

Disturbed Sensory Percep@on: 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.

0:0 Patient
0

0:0 You checked scene safety. It was correct to check

0 scene safety in order to maintain your own safety.

0:0 You introduced yourself.

6

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0:3 You washed your hands.
2

0:4 You identified the patient.

0

0:5 You asked if the patient had any known allergies.

4

0:5 You performed medication reconciliation.

9

1:3 You measured the temperature.

4

1:5 You checked the pulse oximetry.

7

2:2 You checked the radial pulse.

2

2:3 You assessed the respiration.

4

2:4 You measured the blood pressure.

6

3:1 You auscultated the lung sounds.

2

3:2 You auscultated the heart sounds.

5

3:4 You checked the patient's skin.

0

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3:5 You observed the appearance.
7

4:1 You assessed the attention.

9

4:2 You observed the motor activity.

7

4:3 You assessed the speech.

8

4:4 You assessed the thought processes.

4

5:2 You asked the patient: Can you tell me a little bit more
1 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.

5:4 The patient said: They came and got me and forced
1 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.

5:4 You asked the patient: Over the past year, when did
5 you feel your best? It was appropriate to ask the
patient about when he felt his best.

6:0 The patient said: Are you one of those spies too? The
1 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.

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6:1 You asked the patient: Over the past year, when did
4 you feel your best? The patient said: I can't think of
any occasions.

6:2 You asked the patient: Do you have any pain? The
5 patient said: No, I don't have any pain.

6:4 You asked the patient: Have you had any changes in
0 your appetite over the past month?

6:5 The patient said: I'm not going to eat; no one can
4 make me eat poison.\nYou answered: Have you had
similar experiences? \nYou used the therapeutic
technique of encouraging comparison.

7:0 You asked the patient: Do you get hungry? The patient
0 said: Yes.

7:0 You asked the patient: How many meals do you eat
6 each day?

7:2 The patient said: I'm not going to let them hack me.
2 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.

7:2 You asked the patient: Have you lost or gained weight
5 over the past month? The patient said: Gained about
20 pounds. Started about a year ago when they gave
me new meds.

7:3 You asked the patient: Do you notice that your clothes
5 are fitting looser or tighter than they were a few weeks
ago? The patient said: They are the same.

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7:4 You asked the patient: Tell me about any changes you
7 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.

8:0 You asked the patient: Do you nap during the day? If
0 so, how often and for how long? The patient said:
Yeah, I sleep in the afternoon sometimes.

8:0 You asked the patient: Do you have any trouble falling
9 asleep? The patient said: No, not usually.

8:1 You asked the patient: Do you wake up in the early

4 hours of the morning and have trouble returning to
sleep? The patient said: No, not usually.

8:2 You asked the patient: Do you have nightmares or vivid

2 dreams on a regular basis? The patient said: No, not
usually.

8:2 You asked the patient: Approximately how many hours

8 of sleep do you get each night? The patient said:
Lately about 12 hours and I am still tired.

8:3 You asked the patient: Do you have energy to do the

5 normal activities necessary to get through the day?
The patient said: I feel tired all the time.

8:4 You asked the patient: Do you have energy to do the

2 activities that give you enjoyment? The patient said:
No, not really.

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8:5 You asked the patient: I would like to ask you a series
0 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.

9:0 You asked the patient: Do you feel alert to answer

8 questions?

9:2 The patient said: The spies talk about me all the time. I
2 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.

9:3 You asked the patient: How would you describe your
7 mood?

9:5 The patient said: I'm drowning.\nYou answered: Are

0 you suggesting that you feel overwhelmed? \nYou
used the therapeutic technique of translating into
feelings.

9:5 You supported the patient about hearing voices.

9

10: You asked the patient: Please tell me your name. The
16 patient said: David Carter.

10: You asked the patient: Please tell me your name. The
20 patient said: David Carter.

10: You asked the patient: Can you tell me where we are?
25 The patient said: Is this a hospital?

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10: You asked the patient: Please tell me what today's
29 date is. The patient said: (No response)

10: You asked the patient: Have you lost interest in

35 activities that you once enjoyed? The patient said: I am
too busy with the voices to do anything.

10: You asked the patient: Are you frightened of anything?

59

11: The patient said: All of you are part of it, aren't you?
13 You are all in it together!\nYou answered: I notice that
you appear uncomfortable. \nYou used the therapeutic
technique of making observations.

11: You administered lorazepam.

25

11: You asked the patient: Have you lost interest in

44 activities that you once enjoyed? The patient said: I am
too busy with the voices to do anything.

11: You asked the patient: Name an activity that you enjoy.
52 The patient said: I don't know.

11: You asked the patient: Can you name the last five
58 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.

12: You asked the patient: Can you tell me what you ate
19 for breakfast? The patient said: I didn't eat because of
the poison.

12: You asked the patient: Do you have any thoughts or

26 wishes to harm or kill yourself?

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12: The patient said: I can't do this anymore.\nYou
37 answered: Are you considering hurting yourself or
someone else? \nYou used the therapeutic technique
of seeking information.

12: You asked the patient: Have you ever tried to harm or
40 kill yourself? The patient said: No.

12: You asked the patient: Do you think it would be better

47 if you were not alive? The patient said: No.

12: You asked the patient: Do you have any thoughts or

52 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.

13: You asked the patient: Have you ever tried to harm or
05 kill somebody else? The patient said: No.

13: You asked the patient: Can you tell me what a desired
11 outcome of treatment would be for you?

13: The patient said: I have to get out of all this poison. It's
25 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.

13: You supported the patient about reality of voices.

26

13: You supported the patient about safe environment.

33

13: You supported the patient about hearing voices.

37

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13: You asked the patient: How do you understand your
53 problems?

14: The patient said: They got to my mom; they will get to
09 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.

14: You asked the patient: Do you find that you worry
14 more than others?

14: The patient said: I tried to warn everyone.\nYou

24 answered: You tried to warn everyone? \nYou used the
therapeutic technique of restating.

14: You supported the patient about hearing voices.

28

14: You supported the patient about reality of voices.

32

14: You asked the patient: Are you frightened of anything?

43 The patient said: I am frightened of the poison in my
food and when they listen to my thoughts.

15: You educated about the psychiatric diagnosis.

10

15: You educated about daily living.

38

15: You educated about discharge.

56

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 16: You educated about medications.
18

17: You called the charge nurse. You should complete and
10 submit the mental status examination assessment
form before calling the charge nurse.

19: You submitted the Mental Status Examination form.

06 Some of your assessment answers were incorrect.
\n\nRegarding the indicator "2. Psychomotor behavior.
Abnormal movements or gestures": You should have
indicated "No."\n\nRegarding the indicator "3. Mood.
Indicate mood": You should have indicated:
"Anxious."\n\nRegarding the indicator "6. Thought
content. Indications of": You should have indicated
"Delusions" and "Worries."\n\nRegarding the indicator
"11. Orientation and cognitive functions. Orientation.":
You should have indicated "Person" and
"Place."\n\nRegarding the indicator "11. Orientation
and cognitive functions. Memory.": You should not
have checked any indications.\n\n

You should support the patient in choosing food that

feels safe for him.

You should assure the patient that the health care

team will help him.

19: You called the charge nurse. This is reasonable at this

11 point.

6. Document your handoff report in the SBAR format to communicate the care plan for Mr. Carter to the
nurse on the next shiW.

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