Question

Evaluation: Sixty Minutes Later... You go into the patient's room to re-evaluate his status. He states to you, "There are people who want to get me!" Ron becomes agitated and looks you in the eye and angrily states, “Who the hell are you and what are you doing in my house!" You tell him that he is at the hospital and in a safe place. He replies, "I am at home and what the hell are you doing here!" He suddenly takes his right arm and attempts to punch you and narrowly misses your face... 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 2. Has the status improved or nor as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care! (Management of Care) CURRENT Nursing PRIORITY: Expected Outcome PRIORITY Nursing Interventions: Rationale:

Answer 1

Ans

Relevant data- person has memory loss and pyschotic

As he don't know the place

Significance- due to loss of memory aur psychatric problem like delusion he attack doctor

Ans

Evelation- ask the patient about theplace where he is and talk with him to know about the condition if he has delusion

Modification- if there is no improvement the check for tge change in environment around the patient because he may develop traumatic psychosis and may be not improving from delusion

Ans

Improvement in the place and person distribution of mimd of the patient

Doctor wants to stabilize the patient and improve the mental status via antipyschotic DRUG like -SSRI,VERAPAMIL ,CITALOPRAM

Nurting intervention- regular check about the behaviour of the patient and notice the wording of patient that he use