NR 326 iHuman Case Emergency Assessment & Plan - James Mason

584917627384710/14/25, 12:23 PMi-Human - Nurse Notes 456425210245James Mason: Hannah Henderson, Attending 3524258667750Learning Mode (Review) EHR History Physical SBAR Analyze Actions Nurse Notes Time Now Summary 11:40 Situation: James Mason is a 21-year-old Caucasian male, in the emergency department due to paranoid behavior. James is known to the ED and behavioral health care team. Background: James was brought to the emergency department by mall security. It is reported that James accused a store owner of stealing his money. James refused to leave the store. James had been fired from this particular store 6 weeks ago. "He just was not reliable". James is diagnosed with schizophrenia and has been hospitalized multiple times for bizarre behavior, the last time was 4 months ago, here. He last saw his PCP 6 months ago, per our records. He lives with his dad; it sounds like his dad helps with shopping, finances, and maybe setting up medications. Labs were drawn in the ED. The medical record shows aripiprazole 15 mg ordered daily. Assessment: Case's Findings Behaviors Findings Behaviors 6168181-2007382EHR: Recent job loss Hx: Nonadherence with pharmacology EHR: Cannabis use EHR: Tobacco use Hx: Cannabis use Comfort EHR: Headache Hx: Headache Cognition EHR: Poverty of speech EHR: Inattentive and preoccupied EHR: Mumbling quietly to himself Hx: Hears voices Px: Memory problems Px: Inattentive Px: Bothered by external stimuli Mood/Affect EHR: Psychological stress/distress EHR: Recent job loss Hx: Nonadherence with pharmacology EHR: Cannabis use EHR: Tobacco use Hx: Cannabis use Comfort EHR: Headache Hx: Headache Cognition EHR: Poverty of speech EHR: Inattentive and preoccupied EHR: Mumbling quietly to himself Hx: Hears