Planning/Implementation/Evaluation Nursing Diagnosis: Disturbed sensory perception related to biochemical imbalances for sensory distortion as evidenced by hallucinations, delusions,

blunted affect, disorganized thought processes and labile mood. Long-term Goal: The patient will have an undisturbed sensory perception. Intervention 1) Assess vital signs q4h. Rationale 1) Vital signs provide data that determines the patients state of health. Assessment of vital signs provides data to identify nursing diagnosis, implement interventions, and evaluate outcomes of care. An alteration in vital signs signals a change in physiological function and the need for intervention. A patient on anti-psychotic medication is at risk of developing orthostatic hypotension. Assess VS will help prevent injury. (Perry and Potter, pg. 441) 2) Monitoring the patients complete blood count gives information regarding their white blood cell, red blood cell, hemoglobin, hematocrit, and platelet counts. A patient on antipsychotic medications are at risk of developing blood dyscrasias. Monitoring blood counts, especially WBC, will help monitor for thrombocytopenia, leukopenia, and leukocytosis that can be caused by anti-psychotic medications. (Davis Drug Guide, pg. 1080, 181) 3) Assessing the patients behavior Outcome Criteria 1) The patients systolic blood pressure will remain >90 mmHg and diastolic blood pressure will remain >60 mmHg within 48 hours. Evaluation 1) Unmet. The patient was discharged before evaluation could be made. Patient has a history of hypertension and CAD that increases her risk for abnormal blood pressure levels.

2) Monitor CBC q week.

2) The patients WBC count will remain between 5,000-10,000 within 1 week.

2) Unmet. The patient was discharged before an evaluation could be made of her complete blood counts.

3) Assess patients behavior q

3) The patients behavior will not

3) Unmet. The patients behavior

day.

4) Assess patients affect q day.

5) Assess patients thought processes q day.

6) Assess patients perception q day.

will identify any disturbances. A patient with schizophrenia may exhibit incoherent and disorganized behavior. They may be impulsive and uninhibited. They may be socially withdrawn and neglectful of their personal hygiene. A schizophrenia patient may also exhibit echopraxia: the repetition of another persons movements. (HESI, pg. 346) 4) Assessing the patients affect will help identify any disturbances. A patient with schizophrenia may have a change in their affect including blunted or flat affect. They may also present with an appropriate affect or one that is incongruent with the context of the situation. (HESI, pg. 345) 5) Assessing the patients thought processes allows the nurse to observe for any disturbances. A patient with schizophrenia may have delusions: fixed false beliefs that may be persecutory, grandiose, religious, or somatic in nature. They may also exhibit ideas of reference: the belief that conversations or actions by others have reference to them. (HESI, pg. 345) 6) Assessing the patients perception allow the nurse to identify any disturbances. A patient with schizophrenia may exhibit hallucinations: false sensory perceptions that are

have any disorganized or incoherent behavior within 2 weeks.

was still disorganized at last encounter. The patient has subsequently been discharged and further evaluation cannot be completed.

4) The patients affect will change from blunted to normal within 2 weeks.

4) Unmet. The patients affect at last encounter was blunted. The patient has since been discharged making further evaluation unattainable.

5) The patients thought processes will be organized within 2 weeks.

5) Unmet. The patients thought processes continued to be disorganized throughout the clinical weekend. The patient was discharged before further evaluation could be completed.

6) The patients hallucinations and delusions will be resolved within 2 weeks.

6) Unmet. The patient was discharged before evaluation of her delusions or hallucinations could be completed.

7) Assess patients verbal communication q day.

8) Establish trust q day.

9) Refer patient to www.nami.org by discharge.

usually auditory or visual in nature. They may also exhibit illusions: a misinterpretation of their external environment. Schizophrenia patients may exhibit depersonalization: they perceive themselves as alienated or detached from their real body. (HESI, pg. 345) 7) Assessing the patients verbal communication will help identify any abnormalities. A patient with schizophrenia may exhibit looseness of association: the lack of a clear connection from one thought to another. They may also have tangential or circumstantial speech: failing to address the original point, giving many nonessential details. They may have echolalia and neologism where they constantly repeat what is heard or create new words. (HESI, pg. 345) 8) Trust plays a very important role in client and caregiver relationships. Establishing trust will allow the client to open up and discuss their feelings openly. Open communication allows the client to feel like they can express themselves without feeling judged. (HESI, pg. 346) 9) NAMI is a website that provides the client with information regarding mental illness, treatment, and support. This organization also advocates

7) The patient will speak clearly and coherently within 2 weeks.

7) Unmet. The patient was discharged before evaluation could be made as to whether her communication skills had improved or not.

8) The patient will open up and discuss their feelings openly within 1 week.

8) Unmet. The patient has been discharged. She did hold a long conversation with me; however she did not open up about any feelings or concerns she may be experiencing before discharge.

9) The patient will be referred to www.nami.com by discharge and verbalize the rationale behind the website within 24 hours.

9) Unmet. The patient was discharged and it is unknown of whether she was provided with the information about the www.nami.org website.

10) Assess for akathisia q day.

for access to services, treatment, supports, and research related to mental illness. They also try to raise awareness and build a community for hope for all of those in need. (www.nami.org) 10) Akathisia is motor restlessness and an intolerance of inactivity. This symptom may appear as a side effect of anti-psychotic therapy. A patient exhibiting symptoms of akathisia may be unable to sit still, appear jumpy, or distracted. (Tabers, pg. 70) 11) Tardive dyskinesia is a neurological syndrome. In this syndrome, the patient has slow, rhythmical, stereotyped movements that are either generalized or in single muscle groups. These occur as undesired effect of therapy with antipsychotic medications. (Tabers, pg. 706) 12) Dystonia is a prolonged involuntary muscular contractions. These contractions may cause twisting of body parts, repetitive movements, and increased muscular tone. Patients taking anti-psychotic medications may develop dystonia as a side effect. (Tabers, pg. 712) 13) Abilify is an anti-psychotic and mood stabilizer. This medication antagonizes dopamine

10) The patient will not exhibit any signs or symptoms of akathisia throughout their anti-psychotic therapy.

11) Assess for tardive dyskinesia q day.

11) The patient will not exhibit any signs or symptoms of tardive dyskinesia throughout their antipsychotic therapy.

12) Assess for dystonia q day.

12) The patient will not exhibit any signs or symptoms of dystonia throughout their anti-psychotic therapy.

13) Administer Abilify 30 mg PO once a day.

13) The patient will not exhibit any hallucinations or delusions within 2 weeks.

10) Met. The patient did not exhibit any signs or symptoms of akathisia throughout the clinical weekend, but will need to be continuously monitored for this side effect. The patient was discharged and should still be monitored through outpatient services for akathisia. 11) Met. The patient did not exhibit any signs or symptoms of tardive dyskinesia throughout the clinical weekend, but will need to be continuously monitored for this side effect. The patient was discharged but should be monitored for the signs and symptoms of tardive dyskinesia through outpatient services. 12) Met. The patient did not exhibit any signs or symptoms of dystonia throughout the clinical weekend but will need to be continuously monitored for this side effect. The patient was discharged but should be monitored for signs or symptoms of dystonia through outpatient services. 13) Unmet. The patient still exhibited delusions and hallucinations throughout the

and serotonin receptors. The therapeutic effects include decreased manifestations of schizophrenia and mania, decreased agitation and decreased emotional and behavioral symptoms of irritability. (Davis Drug Guide, pg. 179-182) 14) Administer Seroquel 50 mg 14) Seroquel is an anti-psychotic PO daily at HS. and mood stabilizer. This medication acts by antagonizing dopamine and serotonin. It also antagonizes histamine and alpha adrenergic receptors. The therapeutic effects include decreased manifestations of psychoses, depression, and acute mania. (Davis Drug Guide, pg. 1079-1081) 15) Administer Seroquel 50 mg 15) Seroquel is an anti-psychotic PO once q morning prn and mood stabilizer. This medication acts by antagonizing dopamine and serotonin. It also antagonizes histamine and alpha adrenergic receptors. The therapeutic effects include decreased manifestations of psychoses, depression, and acute mania. (Davis Drug Guide, pg. 1079-1081) 16) Provide safe environment q 16) Providing a safe environment day. will help to prevent injury to the patient and staff. Providing a safe environment will also help to provide a therapeutic milieu. A patient who receives care in a therapeutic milieu will be more receptive to therapy and open up

clinical weekend. The patient has since been discharged making further evaluation unavailable.

14) The patient will take Seroquel 50 mg PO daily without any episodes of noncompliance within 2 weeks.

14) Met. The patient agreed to take Seroquel as prescribed by HCP before discharge. The patient should be monitored and the importance of the medicine regime should be reinforced through outpatient services.

15) The patient will verbalize any need for a prn dose of Seroquel if needed within 48 hours.

15) Unmet. Patient was discharged and it is unknown whether she received any prn doses of Seroquel or not.

16) The patient will remain injury free upon discharge.

16) Unmet. The patient fell in the bathroom and hit the back of her head. A CT was performed and deemed negative. The patient is still at risk of injury, especially from the use of her anti-psychotic medications.

17) Encourage patient to identify positive characteristics q day.

18) Teach patient to change positions slowly q day.

19) Teach patient to avoid alcohol q day.

20) Teach patient avoid antacids q day.

to express their feelings more. (HESI, pg. 322) 17) A patient with schizophrenia exhibit delusions and hallucinations. They may also exhibit depersonalization that makes them feel like they are alienated or detached from their body. These feelings make them at a high risk of having negative feelings toward themselves. Encouraging the patient to identify positive characteristics will increase their self-esteem and reinforce congruent thinking. (HESI, pg. 345-346) 18) A patient with schizophrenia is usually treated with anti-psychotic medications. A patient who is receiving anti-psychotic medications are at risk of developing orthostatic hypotension. Teaching the patient to change positions slowly will help to prevent changes in their blood pressure. (Davis Drug Guide, pg. 179-182, 1079-1081) 19) A patient with schizophrenia is treated with anti-psychotic medications. Alcohol acts a depressant on the central nervous system. Anti-psychotic medications interact with alcohol causing a more severe depressant and/or sedative effect. (Tabers, pg. 71-72) A patient with schizophrenia is treated with anti-psychotic

17) The patient will identify one positive characteristic about themselves within 24 hours.

17) Unmet. The patient was discharged before being able to encourage the patient to identify positive characteristics of herself.

18) The patient will verbalize the understanding of the importance to change positions slowly within 24 hours.

18) Unmet. The patient was discharged and it is unknown if she was cautioned to change positions slowly or not.

19) The patient will verbalize the 19) Unmet. The patient did not understanding of the importance of verbalize the importance of avoiding alcohol within 24 hours. avoiding alcohol. She had mentioned that she was going to live it up like New Years Eve over clinical weekend.

20) The patient will verbalize the importance of avoiding antacids

20) Unmet. The patient was discharged without verbalizing the

21) Teach patient s/s of extra pyramidal syndrome q day.

22) Teach patient to notify HCP if they experience suicidal thoughts q day.

23) Refer patient to substance abuse counseling by discharge.

medications. A patient taking antacids with an anti-psychotic will reduce the absorption of the medication. Teaching the patient to avoid antacids will prevent absorption problems with their anti-psychotic medications. (Davis Drug Guide, pg. 1079-1081, 179182) A patient with schizophrenia is treated with anti-psychotic medications. An anti-psychotic may cause signs and symptoms of extra pyramidal syndrome. The signs and symptoms include muscle rigidity, tremors, bradykinesia, and difficulty walking. (Tabers, pg. 834) 22) A patient with a history of mental illness is at a higher risk of having suicidal thoughts. A patient who has schizophrenia is at a high risk of suicide because of their perception is disturbed. Teaching the patient to report any suicidal tendencies will help treat their symptoms before they become serious enough to act upon. (HESI, pg. 341) 23) Sustained abstinence is the primary long term goal of alcohol dependency. Patients seeking care for health problems that causes an interference with their usual pattern of substance abuse, the patients awareness of problems associated with addictive behaviors is increased.

within 24 hours.

importance of avoiding antacids.

21) The patient will verbalize the understanding and importance of recognizing and reporting the signs and symptoms of extra pyramidal syndrome within 24 hours.

21) Unmet. The patient was discharged without verbalizing the signs or symptoms of EPS.

22) The patient will verbalize the importance of notifying their HCP if she exhibits any suicidal thoughts or tendencies by discharge.

22) Unmet. The patient was discharged without acknowledging the importance of notifying the HCP of suicidal thoughts or tendencies.

23) The patient will be referred to a substance abuse counseling center by discharge.

23) Unmet. The patient was discharged without a referral to substance abuse counseling.

24) Refer patient to outpatient psychiatric services by discharge.

25) Refer patient to social services by discharge.

26) Refer patient to smoking cessation support group by discharge.

Intervention at this time can be a crucial factor in promoting behavioral change. (Lewis, pg. 176) 24) Psychiatric treatment will help the patient modify their behavior and focus on the consequences of their actions. Psychiatric services can also help the patient replace their irrational beliefs or distorted attitudes with healthier beliefs and overcome difficulties. A psychiatrist can help monitor the patients signs and symptoms of schizophrenia and monitor the medication effectiveness. HESI, pg. 322-324, 346) 25) Many older adults live on fixed incomes. They may need assistance in finding housing arrangements because of their decreased income and the inability to afford proper housing. Social services will help the patient find a safe and livable housing alternative. (Lewis, pg. 69-71) 26) Tobacco use is the leading cause of preventable illness and death in the U.S. Every health professional is responsible for identifying tobacco users and providing them with information on ways to stop the use of tobacco. A combination of nicotine replacement products, medications, behavioral approaches, and support is believed to be the most effective in

24) The patient will be referred to an outpatient psychiatric service by discharge.

24) Unmet. The patient was discharged. It is unknown whether she was set up with an outpatient provider.

25) The patient will be referred to social services to set up housing for the patient by discharge.

25) Unmet. The patient was discharged. It is unknown if she was provided a social services referral or not.

26) The patient will be referred to a smoking cessation support group by discharge.

26) Unmet. The patient was discharged. Unknown whether she was provided a referral to smoking cessation group or not.

27) Monitor CMP q month.

28) Reinforce congruent thinking q day.

29) Encourage recognition of distorted reality q day.

long term smoking cessation. (Lewis, pg. 170) 27) Seroquel and Abilify are antipsychotics. These medications may cause an increase in creatinine, AST, and ALT levels. If these levels become abnormal, the patient is at risk of developing further complications, especially to the liver. (Davis Drug Guide, pg. 1080, 180) 28) Congruent thinking is having a feeling or emotion that is consistent with their affect. A client with schizophrenia may experience abnormalities in their affect and mood. Reinforcing congruency will help the client to recognize the appropriate reaction to their emotions or feelings. (HESI, pg. 346) 29) Distorted reality is a misrepresentation of the facts or of what is happening. A distorted reality increases the clients risk of injury to themselves and to others. The goal of presenting reality is to indicate an alternative line of thought for the client to consider. (HESI, pg. 346)

27) The patients AST levels will remain between 10-20 U/L and ALT levels will remain between 10-28 IU/L within 1 month.

27) Unmet. The patient was discharged before evaluation of the patients AST and ALT levels could be made.

28) The patient will verbalize the rationale behind reinforcing congruent thinking within 24 hours.

28) Unmet. The patient was discharged before congruent thinking could be reinforced.

29) The patient will verbalize a recognition of any experiences of distorted reality and state an alternative line of thought within 1 week.

29) Unmet. The patient was discharged before any teaching regarding recognition of distorted reality could be completed.

Sources: April, V.P.R.F., Sanoski BS., PharmD., FCCP., BCPS., C., and Deglin PharmD., J. (2013). Daviss Drug Guide for Nurses. Philadelphia: F.A. Davis Company.

Donna, Boyd., & HESI. (2011). HESI Comprehensive Review for the NCLEX-RN Examination. St. Louis, MO: Elsevier. NAMI: National Alliance on Mental Illness - Mental Health Support, Education and Advocacy. (n.d.). Retrieved from http://www.nami.org Patricia, P.R.M.P.F., Perry R.N., Ed., FAAN., Stockert R.N., BSN., MS., PhD., P., and Hall R.N., BSN., MS., PhD., CNEA. (2013). Fundamentals of Nursing. St. Louis, MO: Elsevier. Sharon, Lewis. R.N., PhD., FAAN., Ruff Dirksen, R.N., PhD., S., McLean Heitkemper R.N., PhD., FAAN, M., Bucher, R.N., PhD., CEN., and Camera, R.N., MSN., ND., I. (2001). Medical-Surgical Nursing. St. Louis, MO: Elsevier. Taber, C. W., & Thomas, C. L. (1985). Taber's Cyclopedic medical dictionary. Philadelphia: F.A. Davis.