Question

Mental Health Nursing 1) Write 3 Nursing Diagnosis in regards the patient below 2) Choose 1 of the 3 Nursing diagnosis and Provide 1 short term and 1 longterm goal 3) provide 4-5 interventions for each goal 4) provide 4-5 outcomes for each intervention Reason for admission: Patient was found wondering around Princeton University. Patient is thin and malnourished and unable to care for self. Patient is refusing to cooperate. She is lying fetal position on the stretcher. Procedure Treatment: 2/19/19, 65 year old Chinese descendant received from received from crisis, mobile outreach was used to ED. Reportedly patient was found wondering in the Princeton University Campus. Disheveled, dirty, confused, disorganized, + paranoia. Homeless at present, delusional- wanted to teach, thinks family wants to kill her. Dx-Unspecified psychosis, Hx of 40 years + Schizophrenia, Hx of in patient psych in Maine, China, Riverview, and Mclean Hospital. NKDA, Medical Concern- scleroderma. Nonsmoker, UDS-Ve, BAL <10. On assessment, patient is small stature, wearing eye glasses, drowsy post Haldol 5mg and Ativan 2mg IM in ED at 1231. Unable to participate in interview process, admission completed via medical records, will medicate PRN and as ordered. Will provide coping skills via group/ MILEU Therapy on Q15min. Check for Behavior, will continue Monitoring. Will assess for Flu and Pneumo Vaccines when patient is more Alert. 3/15/19 @ 0300, patient continued to have poor sleeping pattern awake every 1 ½ asking for apple juice and ensure.

Nursing Diagnosis 2. Nursing Diagnosis: Short term Goal: Interventions: Outcomes 2. 2. 4. 4. 5. Long term Goal: Interventions: Outcomes 2. 2. 4. 5.

Answer 1

Nursing Diagnosis

• 1.Disturbed thought process related to physiological brain dysfunction ,as evidenced by stated belief that staff members are really actors who were hired by parents to watch the patient.
• Impaired verbal communication related to formal thought disorders,as evidenced by loose association.
• Disturbed sensory perception related to physiological brain dysfunction ,as evidenced by inappropriate sexual advances towards members of both genders.

Nursiing Diagnosis

Disturbed thought process related to physiological brain dysfunction ,as evidenced by stated belief that staff members are really actors who were hired by parents to watch the patient.

Short term goals

The patient will describe delusions and other disturbed thought process

Interventions

• Demonstrate attitude of caring and concern.
• Validate the meaning of communication with the patient.
• Help the patient identify the difference between reality and internal thought process.
• After 8 hrs of nursing intervention,the patient will identify ways to compensate for cognitive impairment and memory .
• Demonstrate behaviours to minimize changes in mentation.

Outcomes

• The patient will demonstrate attitude of caring and concern.
• Validates the meaning of communication with the patient.
• Helped the patient to identify the difference between reality and internal thought process.
• Identify ways to compensate for cogni

Long term goals

• Client will demonstrate use of more adaptive coping skills.
• After RLE rotation the patient was able to maintain usual reality orientation.

outcomes

• Client will be able to appraise situations realistically and to refrain from projecting own feelings onto the environment.
• After RLE rotation the patient was able to maintain usual reality orientation.