Question

SCENARIO:

Mr. M, a 42-year-old thin male with a history of schizophrenia, is brought to the emergency room from an assisted living facility because of worsening delusions along with hypertension. Staff at the assisted living home reported that he has been increasingly agitated and physically aggressive at times. His delusions consist of creatures from outer space who are trying to kill him. He appears to be experiencing visual hallucinations and states that he sees creatures in the corner of the room telling him to hide. He recently has withdrawn from others and has difficulty initiating activities of daily living (ADLs) such as washing his face and combing his hair. His affect is flat. Later, Mr. M is admitted to the Psychiatric Unit and is prescribed Haldol which is a first-generation antipsychotic. However, after a few days, Mr. M has some muscle stiffness and it is also determined that newer 2nd generation antipsychotic medication would be more helpful to address both positive and negative symptoms of schizophrenia. Seroquel 100 mg is ordered daily and the Haldol stopped. Soon, Mr. M is responding well to the medication with a decrease in hallucinations and agitation. He is being discharged back to the assisted living facility.

QUESTION:

Describe the nursing care plan for Mr. M using the nursing process (Assessment, diagnosis, planning and outcomes, implementation, and evaluation).

Answer 1

Assessment - patient will develop trusting relationship with nurse within reasonable period of time.

Nursing diagnosis - impaired social interaction related to absence of available significant or peers as evidenced by dysfunctional interaction with peers, family.

Planning - encourage patient to to express honest feeling in relation to loss of prior level of functioning.

Implementation - spend time with patient. Develop a therapeutic nurse patient relationship through contact and accepting attitude.

Evaluation - patient shows willingness and desire to socialise with others.