Mental Health Case- David Carter, Part 2 Documentation Assignments
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Course
NUR MISC (NURMISC)
Institution
Stony Brook University
Mental Health Case- David Carter, Part 2 Documentation AssignmentsMental Health Case- David Carter, Part 2 Documentation AssignmentsMental Health Case- David Carter, Part 2 Documentation Assignments
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS
scale.
Mr. Carter did not have any abnormal facial expression and did not clench or bite his jaw.
Another finding was that he did not smack or pout his lips, and his did make any abnormal
tongue movements. In terms of his extremities, all movements were within normal range,
including his neck, shoulders, and hips. He did not have tremors, either. Due to his missing
teeth, Mr. Carter wears dentures.
2. Document Mr. Carter’s performance of activities of daily living and his intake and
m
output for the day.
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Mr. Carter is less paranoid and denies having any more hallucinations. He has an organized
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thought process and appears clean and dressed appropriately. No intake or output was
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recorded except for the fact that he is adhering to his medication regimen and eating some
hospital food. rs e
ou urc
3. Document all laboratory tests ordered for Mr. Carter and their results.
o
Sodium (Na+) =140 Hemoglobin (Hgb)= 15.5
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vi y re
Potassium (K+) =3.9 Hematocrit (Hct)= 43
Chloride (Cl-)= 102 White Blood Cells (WBC)= 7
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Bicarbonate (HCO3-) =24 Platelets= 185
ar stu
Blood Urea Nitrogen (BUN) =18
Creatine= 0.7
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4. Identify and document key nursing diagnoses for Mr. Carter.
Disturbed Thought Process
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Anxiety
Impaired Social Interaction
Social Isolation
Risk for Loneliness
Readiness for enhanced health management
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