Active Classroom Lesson Plan for Townsend, Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice
Learning Activity 6.1.
The Nursing Process: A Case Study
Read the case study and answer the questions that follow.
Sam is presented through the emergency department to the psychiatric unit of a major medical center. He was
taken to the hospital by police, who were called by department store security personnel when Sam frightened
shoppers by yelling loudly to “imaginary” people and threatening to harm anyone who came close to him.
On the psychiatric unit, Sam keeps to himself and walks away when anyone approaches him. He talks
and laughs to himself and tilts his head to the side, as if he were listening to something. When the nurse
attempts to talk to him, he shouts, “Get away from me! I know you are one of them!” He picks up a chair, as if to
use it for protection.
Sam’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. The physician admits Sam with a diagnosis of schizophrenia and orders
Thorazine and Cogentin on both a scheduled and prn basis.
1. Identify four segments of information from the assessment data that would be significant to nursing.
a. ______________________________________________________________
b. ______________________________________________________________
c. ______________________________________________________________
d. ______________________________________________________________
2. List appropriate nursing diagnoses from analysis of the data identified in question 1.
a. ________________________________________________________________
b. ________________________________________________________________
c. ________________________________________________________________
d. ________________________________________________________________
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Active Classroom Lesson Plan for Townsend, Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice
3. Provide outcome criteria for the four nursing diagnoses.
a. _________________________________________________________________
b. _________________________________________________________________
c. _________________________________________________________________
d. _________________________________________________________________
4. Describe appropriate nursing interventions to achieve the outcome criteria.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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_________________________________________________________________
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_________________________________________________________________
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Active Classroom Lesson Plan for Townsend, Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice
Answers to Learning Activity 6.1.
1. Assessment data
a. Picks up a chair, as if to use it for protection. Threatened to harm anyone who came close to him
in the department store.
b. Talks and laughs to himself and tilts his head to the side.
c. Keeps to himself and walks away when anyone approaches him.
d. Appearance is unkempt. Clothes are dirty and wrinkled, hair is oily and uncombed, and there is
an obvious body odor about him.
2. Nursing diagnoses
a. Risk for other-directed violence
b. Disturbed sensory-perception (hallucinations)
c. Social isolation
d. Self-care deficit
3. Outcome criteria
a. Sam has not harmed himself or others.
b. Sam is able to define and test reality.
c. Sam approaches others in an appropriate manner for 1:1 interaction. Attends group activities
voluntarily.
d. Sam carries out personal care independently and willingly.
4. Some appropriate nursing interventions include:
a. Removing dangerous objects from patient’s environment.
b. Redirecting violent behavior with physical outlets.
c. Having sufficient staff available to indicate show of strength.
d. Administering antipsychotic medication, as ordered (scheduled and prn).
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Active Classroom Lesson Plan for Townsend, Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice
e. Encouraging patient to share content of his hallucinations.
f.
Helping patient to understand that even though the voices seem real to him, others do not hear
the voices.
g. Attending groups with patient until he feels comfortable attending alone.
h. Giving positive feedback for patient’s voluntary interactions with others.
i.
Encouraging patient to be as independent with self-care activities as possible.
j.
Giving positive feedback for self-care activities performed independently.
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Active Classroom Lesson Plan for Townsend, Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice
Homework Assignment Questions and Answers
1. Nursing outcomes (sometimes referred to as goals) are derived from the nursing diagnosis. Name two
essential aspects of an acceptable outcome or goal.
Outcomes or goals should be (1) measurable and (2) estimate a time for attainment.
2. Define managed care.
Managed care refers to a strategy employed by purchasers of healthcare services who make
determinations about various types of services in order to maintain quality and control costs. In a
managed care program, individuals receive healthcare based on need, as assessed by coordinators of
the providership. Examples of managed care are the health maintenance organizations (HMOs) and
preferred provider organizations (PPOs).
3. The American Nurses Association identifies certain interventions that may be performed only by
psychiatric nurses in advanced practice. What are they?
Prescriptive authority and treatment, psychotherapy, consultation
4. Identify three common elements that form the foundation of each of the documentation methods
discussed in the chapter.
The three common elements are assessment, intervention, and evaluation.
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