JJ is presented to the Outpatient Department at ST. Giles Hospital accompanied by a relative and two Police Officers.

 The neighbors contacted the Police this morning because he was acting as if he was shouting at imaginary people and threatened he will harm anyone that tries to come near him. In his room, JJ keeps to himself and will turn to the wall, when someone approaches him. He talks and laughs to himself and tilts his head to the side as if listening. When the nurse attempts to talk to him he shouts “Get away from me. I know you are one of them’’. He picks up the urinal and holds it as if to use it for protection.

JJ’s appearance is unkempt. His clothes are dirty and wrinkled, his hair is oily and uncombed and there is an obvious body odor about him. He was diagnosed with Paranoid schizophrenia and medications were ordered as well.

1 Identify four (4) segments of information from your assessment data that would be significant to nursing

2. List the appropriate nursing diagnoses from analysis of the data described in question 1

3. Provide outcome criteria for the 4 nursing diagnoses

4 Outline appropriate nursing interventions you will expect nurses to provide while JJ is in the hospital

5. For discussion – find out if students can document JJ”s Mental Status examination.

Answer rating: 100% (QA)

1 The persons paranoia may be extreme and they kept acting socially withdrawn decreased self care De... View the full answer