Question

8:59 AM 31 Nursing Care plan revised 2019 (3)-32.pdf INSTRUCTIONS In the following pages you will find the data on your fictional patient. There are 2 case studies, but you only need to complete one of them. Please note whether you chose Case 1 or Case 2 You will need the following for your care plan 2 nursing diagnosis with 3 interventions for each diagnosis. One short term and one long term goal for each diagnosis, and evaluations for each goal to Follow the clinical packet outline in your syllabus for the rest of the assignment. Rubrics for grading are included in the packet. Please cite a reference at the end of your care plan for your work in professional format. Do your own work, this is not a collaboration. If you need more room, you can free text. The following information is based on one of the case studies and NOT A REAL CLIENT Initials: S.C. Age: 27 Gender: M HT: 59" WT: 129 B/P 100/64 P80 R20 Date of Admission: todays date Case Study 1: Medical Diagnosis: schizophrenia Brief description of current admission The client was involuntarily committed for trying to jump off an overpass to commit suicide. The client is actively hallucinating and having paranoid delusions. The client states that people are watching him and trying to kill him. You notice the client engaging in conversations without anyone nearby. The client is dirty with unkempt hair and clothes. The client is thin and malnourished appearing. The client has dry oral mucosa and halitosis. The client states that he is homeless, has no family or friends and has been out of his medications for one month. The client's speech is sometimes incoherent and he rapidly changes subjects with little association. Upon physical assessment, you find the following: Normal findings of heart, lungs and abdomen. Musste devandskinner ser Clients markedly understandsins

Answer 1

Ans:Nursing diagnosis:-1)Disturbed Sensory Perception related to altered sensory perception as evidenced by engaging in conversation without anyone nearby.

Expected outcome: Short term goal :Patient will learn ways to refrain from responding to hallucinations.

Long term goal:

• Patient will state that the voices are no longer threatening, nor do they interfere with his or her life.

Interventions:1)Accept the fact that the voices are real to the client, but explain that you do not hear the voices. Refer to the voices as “your voices” or “voices that you hear”.

2)Help client to identify times that the hallucinations are most prevalent and frightening.

3)If voices are telling the client to harm self or others, take necessary environmental precautions.

Evaluation:patient sensory perception is correct slightly.

Nursing diagnosis:2)Disturbed Thought Process related to inadequate support system as evidence by patient is homeless.

Expected outcome:Short term goal:Patient will verbalize recognition of delusional thoughts if they persist.

Long term goal:

• Patient will develop trust in at least one staff member within 1 week.

Interventions: 1)

Recognizes the client’s delusions as the client’s perception of the environment.		Recognizing the client’s perception can help you understand the feelings he or she is experiencing.
Identify feelings related to delusions. For example: If client believes someone is going to harm him/her, client is experiencing fear. 2.Explain the procedures and try to be sure the client understand the procedures before carrying them out.
Cite references:https://nurseslabs.com/schizophrenia-nursing-care-plans/