Potential complications: -psychosis-induced polydipsia(1) -anxiety disorder(2) -suicide(3) -depressive symptoms(4) -nicotine dependence(5) -substance abuse(6) -social isolation(7) -finical complications(8)
Signs of complications: -S:thirst,O:drinking -S:thirst,O:drinking (1) -S:anger,O:harm to self or others(2) -S:thoughts of suicide, O:attempt suicide(3) -S:depression,O:not -S:depression,O:not performing ADL(4) -S:craving nicotine,O: smoking(5) -S:craving alcohol/drugs,O:using(6) alcohol/drugs,O:using(6) -S:withdraw, 0:no interaction with others(7) -S: no home, O:lives on the street(8)
Interventions for complications: -monitor water intake,use small cups(1) -structure environment,simple creative projects(2) -monitor suicidal thoughts,actions(3) -frequent reminders for ADL, incorporate favorite activity(4) -avoid exposure to smoking, use of patch if established(5) -avoid exposure to alcohol/drugs, maintain prescribed medication regime(6) -joins in social activities, group/individual therapy(7) -establish city funded home, reunite family home(8)
Nursing Diagnosis 1: Disturbed Sensory Perception: auditory Symptoms: -Positive, hallucinations(s),delusions(o),disorganized hallucinations(s),delusions(o),disorganized speech(o),bizarre behavior(o) -negative, blunted affect(o),poor thought(o),loss of motivation(s),anhedonia(s),suicidality(s),hope motivation(s),anhedonia(s ),suicidality(s),hopelessness(s) lessness(s)
Psychopathology: -neurotransmitters, increase in dopamine&norepinephrine, dopamine&norepinep hrine, decrease in GABA -unstable environment, increases stress results in anxiety and depression
Rx therapy: Clozaril antipsychotic
Rx interventions: -agranulocytosis, frequent WBC lab draws -monitor EPS -monitor blood sugar - monitor hypertension
Michelle White 1-27-12 Mental Health
Nursing Diagnosis 2: Disturbed Thought Process
Schizophrenia
Definition: Mental disorder characterized by the breakdown of thought process and emotional response
Risk factors~ -Genetic traits passed -Environment: pregnancy&birth complications, stress, street drug use and alcohol use before age 21
Risk reduction strategies: -genetic screening -pregnancy&birth education -early intervention and preventions of underage drinking and drug use
Assessment: S: Hearing voices others can not hear O: see patient holding verbal conversation with themself Plan: Patient will be free from auditory hallucinations By 1700 on day three of hospital stay Intervention: -medications given at the same time each day -monitor for voices being heard by the patient every four hours&document Evaluation: -At 1700 on day three patient stated he no longer heard voices in
Assessment: S: feel impending doom O: withdrawn stays sitting on the side of bed all day Plan: Patient will walk to door and back to bed by 1700 on the third day of hospital day
Intervention: -Medications given same time each day -Orient to surroundings every four hours&document
Evaluation: -at 1700 on day three patient walked from bed to door and returned to side of bed.
