Question

Mr. Deaner is a 21-year-old African American male who was recently admitted to the inpatient psychiatric unit with a diagnosis of Paranoid Schizophrenia. Because of his violent behaviors, he was started on a high dose of Haldol. On day 7 of Mr. Deaner’s hospitalization, he had a fever of 104 and a BP of 160/110, he was diaphoretic, he appeared to have some muscle rigidity, and was confused. Concurrently, because of the patient’s paranoia, he had been refusing liquids and food. 1.Nursing Diagnosis 2. Treatment Plan. 3.Implementation. 4. Evaluation 5. Recommendations

Answer 1

• Altered body temperature / Ineffective thermoregulation related to disease condition as evidenced by raise in body temperature
• Ineffective tissue perfusion related to increased peripheral vascular resistance as evidenced by increased blood pressure level
• Imbalanced nutrition less than body requirement related to aversion towards food as evidenced by refusing to eat
• Risk for injury self and others related to disease condition as evidenced by violent behaviour
• Disturbed sensory perception related to changes in brain function as evidenced by confusion

Treatment plan and implementation

To reduce body temperature ( antipyretics)

• to meet the nutritional needs of the patient ( IV support)
• to reduce the increased blood pressure level ((anti hypertensive )
• prevention of harming self and others(restraint if needed)
• Counselling therapy to make patient realise self and providing ways to manage the symptoms effectively
• not arguing with patient ,because this may trigger anger and behave more violently
• remove any sharp items or objects from the patient surroundings do that injury can be prevented
• monitor the patient vitals hourly until coming to normal level
• Administer antipsychotic drugs as per order and assess for adverse effects
• provide comfort devices
• Encourage patient to take orally
• involve family members in the treatreatment

Evaluation and recommendations

• evaluate the vital signs periodically
• assess for signs of improvement
• Provide psychological therapy
• Involve in group activities
• Take measures to decrease his aggressive or violent behabbeha