Develop Care Plan: Risk for Assault secondary to AVH and Par
Develop Care Plan: Risk for Assault secondary to AVH and Paranoid… Develop Care Plan: Risk for Assault secondary to AVH and Paranoid Schizophrenia Adam Munroe has a history of Methamphetamine use and paranoia.His recent diagnosis is Schizoaffective disorder upon admission to JGPH. Case History:He refused to leave the Safeway after assaulting the Deli counter person who attempted to redirect him from eating the roasted chicken in the store. Police was called and he was restrained in Highland Emergency Room and placed in 4 point restraints. He recieved Geodon 20 mg IM and a bolus of D5W 1000 cc for dehydration and IV antibotics for an anticubetal abcess secondary to IV drug usage. He is Hepatits C postive and HIV negative. He has scarring on his lungs from previous TB but is no longer infectious. He was treated for lice infestation with one px of NIX and he recieved a hair cut for notted hair. He has an open would on his right arm from IV drug usage and was MRSA positive covered with bacatrcin and DSD. He is COVID negative but methamphetamine positve in his UDS ( urine drug screen)His blood pressure is 150/84 pulse 96 Respirations 20 and o2 sat is 98%. He is alert and orientated x2 but easily agitated and distracted When he arrives on the Gurney at John George He is yelling ” I want a sandwich.” He is homeless and not compliant with psychiatric treatment.This is a problem list: 1) Risk for assault 2) Poor nutrition underweight 3) Risk for self harm and self care deficit secondary to AVH. 4) Methamphetamine dependence and residual psychotic symptoms 5) Poor hygiene- px for head lice x1 in ER. 6) History of Hepatitis C and HIV risk 7) High risk for COVID 8 ) Homeless and unclear income. (2) Nursing Diagnoses(10) Patient Goals(20) Intervention: RationaleImplementation(Yes or No)EvaluationOutcome Before letting him off the gurney what would you ask him? Why would wheeling him into an open quiet room and then releasing him from a gurney be the safest thing to do? Would you be alone with this patient? Would you shut a door in an interview room and be alone with this patient? How could COVID complicate this issue? What would you do if he converted to COVID and did not keep his mask on?Health Science Science Nursing NURSING N129
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