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NEURO

Cognition &
Sensory
Perfusion Oxygenation Elimination
GI/GU
Tissue
Integrity
Mobility Metabolism Mood/Affect Comfort

Disoriented
only oriented
to name

Paranoid

Hallucinating

Cant recall
last shower,
address, or
medical
history

Negative tox
screen














BP 128/86

Pulse 94

Temp 99.0

History of
hypertension
and high
cholesterol
that are
untreated

Respiration 24

Allergy to
peanut and
seafood

HIV Negative

No abnormal
findings

No abnormal
findings

History of
Diabetes
Mellitus that is
untreated

Blood glucose
385

CBC Normal

Found standing in
street, yelling,
acting crazy

Where is Jesus?

Paranoid

Isolative

Hallucinating

Strong Body Odor

Soiled clothing

Multiple shirts and
large coat- 98
degrees outside

Messenger of God
sent to get rid of evil
with bat

Unemployed

History of
schizophrenia
diagnosed at 27

Attempted suicide
3X

Cogentin 1mg PO
QHS

Seroquel 200 mg PO
BID

Desyrel 100 mg PO
QHS

Parents are
scared of
him and
dont want
him in their
house- he
has been
violent with
them.

Parents say
he is
indigent and
they cant
afford him

Haldol shots
q8weeks
he
sometimes
misses the
appointment

Doesnt
regularly see
Dr.

Parents are
in their 70s


Problem List: 1. Safety 2. Blood Glucose/DM 3.Ineffective therapeutic regimen therapy 4. Disturbed thought process
5. History of suicide 6. Self care deficit 7. Support system 8. Disoriented

Nursing DX:

Risk for Self Harm R/T History of suicide
attempted 3Xs


Goal:


The patient will not harm self during shift



Nursing DX:


Ineffective health care maintenance R/T
Schizophrenia AEB missing doses of
Haldol that are scheduled every 8 weeks

Goal:

The patient will understand the
importance of not missing doses of
medication so these episodes dont
happen

Nursing DX:


Disorientation R/T possible
hyperglycemia AEB blood glucose of 358


Goal:

Treat hyperglycemia and patient will be
alert and orient x 3

Nursing DX:


Disturbed thought process R/T
hallucinations and paranoia AEB patient
talking to self, and wanting to rid the evil
out of the world with his magic bat

Goal:

The patient will realize that they are in a
hallucination and calm down

I:

Establish a trusting nurse-client
relationship by actively listening and
providing support


O:
May indicate acceptance and may facilitate
trust preventing the patient wanting to
hurt self


I:

Validate reality by telling patient that you
are not evil, use a quiet calming voice, and
letting them know they are safe, and orient
them.


O:

Orient them to what is going on try to
calm them down so they dont have the
temptation to hurt themselves.

I:

Help the patient set up a schedule to meet
with a physician and way of
transportation to appointment and get his
Haldol there

O:

This will ensure patient receives
physician assessment and his medication
necessary to treat his schizophrenia

I:

Since parents dont want patient living
with them, arrange for patient to live in
assisted living area that a nurse will
always be there and will make sure he
gets his medications

O:

This solves the problem of parents not
wanting him to live with them, and also
ensures that patient will receive

I:

Administer insulin as Dr. order, also set
up medication plan for after patient is
discharged that they will be compliant
with

O:

Treat the hyperglycemia and avoid
another episode of hyperglycemia from
occurring again it may set off
schizophrenia symptoms

I:

Address patient by name; reorient as
needed to place, person, and time. Give
short explanations, speaking slow and
enunciating clearly

O:

Decreases confusion and helps maintain
contact with reality


I:

Do not argue with the patient about the
hallucination or delusions



O:

This will only upset the patient more, and
make them more suspicious


I:

Move the client to a more quiet, less
stimulating environment




O:

Eliminating stimuli will hopefully help the
patient calm down and let the hallucination
pass




I:

Facilitate a safe environment a separate
room close to nurses station, a sitter, a
special room equipped with only a bed,
plastic silverware.

O:

Eliminates the way of hurting themselves
keeps them safe.
medications, and be observed if
symptoms occur

I:

Determine why the patient has been
missing appointments with physician and
why he hasnt been getting his Haldol
injections

O:

Determining the reasons why he isnt
going to his appointments can be the start
of explaining to the patient the
importance of this medication for his
diagnosis also whatever his reason is,
set a plan with the patient to ensure he is
compliant



I:

Monitor neurological status blood glucose
every hour



O:

Prevent a disorientation episode from
happening again



I:

Switch and focus the patient on a
structured activity or task-based reality



O:

This will distract patient from their
hallucination and help calm the patient
down
Evaluation/Revision:

Expected outcome would be that
patient doesnt harm self during shift.
Evaluation/Revision:

Expected outcome would be for the
patient to acknowledge the
importance of regular physician
appointments and the importance of
his haldol injections for treating his
schizophrenia
Evaluation/Revision:

The expected outcome for treating the
hyperglycemia would be that patient
is alert and orient x3
Evaluation/Revision:


Expected outcome would be patient
doesnt experience hallucinations and
eliminate paranoia additional
interventions would probably need to
be done possible medications.