David Carter part 1.,WELL EXPLAINED WITH CORRECT ANSWERS.

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 The patient is disheveled and withdrawn.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 activities 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 medications prior to hospitalization. Olanzapine 10 mg and Venlafaxine 75 mg daily 4. Identify and document key nursing diagnoses for Mr. Carter. Imbalanced nutrition r/t auditory hallucinations as evidenced by Pt verbalizing the food is poisoned, and refusing to eat. 5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to this care. -Checked the scene for safety. -Identified the patient and introduced self. -Asked the patient general questions about well-being, sleep patterns, appetite, and energy levels. -Performed a mental status assessment. -Submitted mental status assessment to charge nurse. -Supported patient in times of agitation, worry, and fright. -Administered Lorazepam 2 mg. -Educated the patient about his diagnoses of Schizophrenia. -Educated the patient about the course of action that will be taken with the healthcare team; medication regimen, dietary assessments and hygiene. -Notified provider using SBAR. 6. Document your handoff report in the SBAR format to communicate the care plan for Mr. Carter to the nurse on the next shift. Situation: David Carter is a 28 year old male, was admitted after he became violent with mother and the police were called. Background: David has a 10 year history of schizophrenia and has been stable on medication (Olanzapine and Venlafaxine). Now, David has refused to take his medication as well not eat anything, for he believes it is poisoned. He has paranoid delusions and auditory hallucinations. Assessment: David hasn’t been eating but stated he would eat a prepacked sandwich if it was packed well. He agreed to take his medication, Lorazepam 2mg. The mental health status examination was completed and submitted to charge nurse. Recommendation: Continue to orient patient to reality and encourage patient to eat and drink fluids.