ACTIVITY 2

Mora, Miguel B. March 28, 2023

BSN 3YB-9 NCMB 317

John Jones, age 33, has been admitted to the hospital for the third time with a diagnosis of paranoid
schizophrenia. John had been taking haloperidol (Haldol) but stopped taking it weeks ago, telling his case
manager it was “the poison that is making me sick.” Yesterday, John was brought to the hospital after
neighbors called the police because he had been up all night yelling loudly in his apartment. Neighbors reported
him saying, “I can’t do it! They don’t deserve to die!” and similar statements. John appears guarded and
suspicious and has little to say to anyone. His hair is matted, he has a strong body odor, and he is dressed in
several layers of heavy clothing even though the weather is warm. So far, John has been refusing any offers of
food or fluids. When the nurse approached John with a dose of haloperidol, he said, “Do you want me to die?”

1. What additional assessment data does the nurse need to plan care for John?

○ The nurse would need to collect assessment information for John. Like John's medical history,
medication schedule, and any allergies or negative medication reactions. To plan care for him, The
nurse must assess, John's mental state, his level of orientation, mood, thought processes, and any
hallucinations or delusions. All these assessment needs to be examine by the nurse. The nurse
would also need to check John's physical condition. Including vital signs, hydration level, and
nutritional condition.

2. Identify the three priorities, nursing diagnoses, and expected outcomes for John’s care with your
rationales for the choices.

○ John's immediate physical requirements, such as hydration and nutrition, managing his
schizophrenia symptoms with medication and therapy, and ensuring his safety could be the three
top priorities for his care. Nursing diagnoses may consist of

- Imbalanced nutrition: less than body requirements, risk for injury related to altered thought
processes,
- Noncompliance with medication regimen related to adverse effects.
- Risk for injury related to altered thought processes

Expected outcomes could include improved nutritional status, decreased risk of injury, and
improved compliance with medication regimen.

3. Identify at least two nursing interventions for the three priorities listed in Question 2.

○ Implementing safety precautions, such as removing potential hazards from the environment.
Administer antipsychotic medication as prescribed and check for side effects. Provide education on
the importance of medication adherence and the probable side effects. This nursing intervention
contributes to addressing the top three nursing diagnosis.

4. What community referrals or supports might be beneficial for John when he is discharged?

○ When John is released from the hospital, community referrals or supports that might be helpful
include a case manager to help with care coordination and resource access; a support group for
people with schizophrenia; and a mental health facility or therapist for ongoing therapy.