Problem based Learning assessment
Nursing diagnosis is a clinical judgement based on a thorough nursing assessment to existing or possible health/life problem. Nursing interventions are then selected by nurses to which they are accountable for, to achieve a desired outcome. (Herdman, p. 515). The paper “Problem Based Learning “is a detailed nursing care plan for Julie, 22year old female, first presentation to a psychiatric unit, with a provisional diagnosis of acute psychotic episode.
1.) Nursing Dioagnosis: “Underweight” Imbalanced nutrition: less than body requirement
Related to inadequate food intake and depressed mood
Evidenced by:
- Objective: Julie is pale, fragile and underweight, low BMI is 19.1
- Subjective: Julie self-reports that she does not like meat anymore and is allergic to seafood.
Expected Outcome: Julie’s oral intake will have increased which will be evidenced by an increase in her weight ().
Short term goals:
Within 24-48hours of admission, Julie will have consumed 25% of each of the meals provided.
Long term goals:
Julie will consume adequate dietary and fluid intake with minimal/no prompts from staff.
Nursing Intervention and rationales:
1.)
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Community psychologist has been appointed as the case manager discuss physical and sexual abuse which could not be further explored as an inpatient. Social worker has arranged for Julie to participate in Richmond Fellowship activities one day a week to encourage socialising with peer groups along with Centrelink services until Julie finds a job. Ongoing social support and education from the community team for Julie’s grandparents especially grandmother in dealing with Julie’s situation and personal wellbeing. Continue medications as prescribed. Provide discharge summary and 7day supply of medications along with phone number of Mental Health Support