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David Carter Part 2 Documentation

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Mental Health Case: David Carter, Part 2 Documentation Assignments 1. Document findings associated with your screening of Mr. Carter using the AIMS scale. The patient had no abnormal facial express ... ion. No smacking, puckering, pouting of the lips and perioral area. No jaw biting or clenching No abnormal tongue movements No tremors or abnormal extremity movements No Abnormal Neck, hip, or shoulder movements. Patient has current problems with teeth and usually wears dentures 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day. David’s thoughts are more organized, and denies having any hallucinations. Paranoia has lessened. He is now eating hospital food and is taking his medications. 3. Document all laboratory tests ordered for Mr. Carter and their results. The doctor has ordered routine blood work to see electrolytes Na= 140 K=3.9 Cl=102 HCO3=24 BUN=18 Cr=0.7 Glucose=92: all within normal range CBC: Hgb= 15.5 HCT=43 WBC=7 Platelets= 185: all within normal range Urine Drug screen result: Negative 4. Identify and document key nursing diagnoses for Mr. Carter. Anxiety related to conflict in life goals or values as evidenced by verbalization of anxiety. 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this care. Checked the scene for safety Asked the patient for his consent for letting his mother to be a part from the interview. Asked general quest [Show More]

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