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Potential complications: Signs of complications: Interventions for complications: Michelle -psychosis-induced -S:thirst,O:drinking (1) -monitor water intake,use small
Potential complications:
Signs of complications:
Interventions for complications:
Michelle
-psychosis-induced
-S:thirst,O:drinking (1)
-monitor water intake,use small cups(1)
White
polydipsia(1)
-S:anger,O:harm to self or others(2)
-structure environment,simple creative projects(2)
1-27-12
-anxiety disorder(2)
-S:thoughts of suicide,
O:attempt suicide(3)
-monitor suicidal thoughts,actions(3)
-frequent reminders for ADL, incorporate favorite
Mental Health
-suicide(3)
-depressive symptoms(4)
-nicotine dependence(5)
-substance abuse(6)
-social isolation(7)
-finical complications(8)
-S:depression,O:not performing
activity(4)
ADL(4)
-avoid exposure to smoking, use of patch if
-S:craving nicotine,O: smoking(5)
-S:craving alcohol/drugs,O:using(6)
-S:withdraw, 0:no interaction with
established(5)
others(7)
-S: no home, O:lives on the street(8)
-avoid exposure to alcohol/drugs, maintain prescribed
medication regime(6)
-joins in social activities, group/individual therapy(7)
-establish city funded home, reunite family home(8)
Nursing
Nursing Diagnosis 1:
Diagnosis 2:
Disturbed Sensory Perception:
Disturbed
auditory
Thought Process
Symptoms:
Schizophrenia
-Positive, hallucinations(s),delusions(o),disorganized
speech(o),bizarre behavior(o)
-negative, blunted affect(o),poor thought(o),loss of
motivation(s),anhedonia(s),suicidality(s),hopelessness(s)
Assessment:
Assessment:
S: Hearing
voices others
can not hear
O: see patient
S: feel impending doom
O: withdrawn stays sitting
on the side of bed all day
Definition:
holding verbal
Plan:
Mental disorder characterized by
the breakdown of thought process
and emotional response
conversation
with themself
Psychopathology:
-neurotransmitters, increase in
dopamine&norepinephrine, decrease in GABA
-unstable environment, increases stress results
in anxiety and depression
Plan:
Patient will walk to
door and back to bed
by 1700 on the third
day of hospital day
Patient will be free
from auditory
hallucinations
By 1700 on day three
of hospital stay
Intervention:
-Medications given
same time each day
Rx therapy:
Risk factors~
-Genetic traits passed
-Environment: pregnancy&birth
complications, stress, street drug
use and alcohol use before age 21
-Orient to
Clozaril
Intervention:
antipsychotic
Rx interventions:
-agranulocytosis,
frequent WBC lab
draws
-monitor EPS
Risk reduction strategies:
-medications given at the
same time each day
-monitor for voices being
heard by the patient
every four
hours&document
surroundings every
four
hours&document
Evaluation:
-genetic screening
-pregnancy&birth education
-early intervention and preventions
of underage drinking and drug use
Evaluation:
-at 1700 on day
three patient
walked from bed
to door and
-At 1700 on day three
-monitor blood sugar
returned to side of
- monitor hypertension
patient stated he no
longer heard voices in
his head.
bed.