NAME: Cañete, Princess Laira V.

BSN 3-YB-18

ACTIVITY 2 MIDTERM

John Jones, age 33, has been admitted to the hospital for the third time with a diagnosis of
paranoid schizophrenia. John had been taking haloperidol (Haldol) but stopped taking it weeks
ago, telling his case manager it was “the poison that is making me sick.” Yesterday, John was
brought to the hospital after neighbors called the police because he had been up all night
yelling loudly in his apartment. Neighbors reported him saying, “I can’t do it! They don’t
deserve to die!” and similar statements. John appears guarded and suspicious and has little to
say to anyone. His hair is matted, he has a strong body odor, and he is dressed in several layers
of heavy clothing even though the weather is warm. So far, John has been refusing any offers
of food or fluids. When the nurse approached John with a dose of haloperidol, he said, “Do
you want me to die?”

1. What additional assessment data does the nurse need to plan care for John?
 The nurse should assess the amount of sleep during the past few days.
 Assess for positive symptoms that the client is manifesting.
 Assess the client medical history, aside from the medication, the nurse can
assess if the client had been hospitalized previously.
 Assess support system. Determine whether the family is well informed about
the disease.
 Assess the reason why the client is no longer complying to medication.
2. Identify the three priorities, nursing diagnoses, and expected outcomes for John’s care
with your rationales for the choices.

PRIORITIES NURSING Dx EXPECTED RATIONALE

OUTCOMES

1. Risk for 1. Risk for 1. The client 1. It would be a

imbalanced imbalanced will start to major issue if
nutrition nutrition verbalize we do not
2. Risk for related to what food stimulate the
insufficient psychological that he likely patient’s
fluid volume disorder as to eat appetite then
3. Disturbed manifested by 2. The client the client
thought insufficient will take at will not eat
processes interest in least 3 for an
food glasses of extended
2. Risk of water period of
 insufficient 3. The client time. This
fluid volume will have 5 might
related to minutes intensify his
psychological interactions anxiety
disorder as that are based 2. Adequate
manifested by from reality oral fluid
refusal of intake is
water intake important
3. Disturbed and if it is
thought not
processes prioritized, it
related to will have a
diagnosis of significant
psychological impact on his
disorder as body and
manifested by increase his
inappropriate anxiety
non-reality- 3. When the
based thinking client
thoughts are
focused on
reality -based
events, he or
she is free of
delusional
thinking.
Helps focus
attention
externally

3. Identify at least two nursing interventions for the three priorities listed in Question 2.

PRIORITIES INTERVENTION

1. Risk for imbalance nutrition  Assess the client preference for

food and why he is refusing to
eat.
 Emphasize importance of food
intake to the client and assure him
that food to be offended will not
2. Risk for insufficient fluid volume harm him.

 Identify the cause of refusal of

oral fluid
  Assess skin turgor and administer
IV fluids as ordered
3. Disturbed thought processes
 Initially do not argue with the
client’s beliefs or try to convince
the client that the delusions are
false and unreal

 Interact with client on the basis of

things in the environment. Try to
distract client from their
delusions by engaging in reality-
based activities

4. What community referrals or supports might be beneficial for John when he is

discharged?
1. Emphasize to the family the importance of social interaction to the patient.
2. Emphasize the importance of having adequate sleep to reduce the client’s
environment
3. Emphasize importance of encouraging the patient’s compliance to treatment
regimen.
4. Educate and develop support networks, for the families reduces the family’s
anxiety, increase their physical and mental health.
5. Educate the family members about the disease and medications used to treat the
disease
6. Provide information on disease and treatment strategies at the family’s level of
understanding
7. Instruct the family to keep the patient from a lot of stimulus that might increase his
anxiety
8. Instruct to report any violence behaviors that the client is manifesting