Mental Health Nursing Process Assignments
Pedro Gonzales, a 37-year-old Hispanic man, arrived by ambulance from a supermarket, where he had fallen. On his arrival at the emergency department (ED), his breath smelled “fruity.” He appeared confused and anxious, saying that “they put the evil eye on me, they want me to die, they are drying out my body … it’s draining me dry … they are yelling, they are yelling … no, no, I’m not bad … oh, God, don’t let them get me!” When his mother arrived in the ED, she told the staff, through an interpreter, that Pedro has severe diabetes and a diagnosis of paranoid schizophrenia. She says with frustraSon, “This happens when he doesn’t take his medicaSons.
In a group or in collaboraSon with a classmate, respond to the following:
1. A number of nursing diagnoses are possible in this scenario. Given the provided informaSon, formulate at least two nursing diagnoses and include related to and as evidenced by as appropriate.
2. For each of your nursing diagnoses, write out one long-term outcome (the problem, what should change, etc.). Include a Sme frame, desired change, and three criteria that will help you evaluate whether the outcome has been met, not met, or parSally met.
3. What specific needs might you consider when planning nursing care for Mr. Gonzales?
4. Using the SOAPIE format to formulate an iniSal nurse’s note for Mr. Gonzales.
S: Subjec)ve data (pa)ent statement)
O: Objec)ve data (nurse observa)ons)
A: Assessment (nurse interprets S and O and describes either a problem or a nursing diagnosis)
P: Plan (proposed interven)on)
I: Interven)ons (nurse’s response to problem)
E: Evalua)on (pa)ent outcome)