Dr. James Malce Alo,RN,MAN,MAPsycho,PhD

1

Nursing C A R E P L A N Schizophrenia

ASSESSMENT DATA Nursing Diagnosis

EXPECTED OUTCOMES

(or Planning)

IMPLEMENTATION

Nursing Interventions *denotes

collaborative interventions

RATIONALE

EVALUATION

• Non–reality-based

thinking

• Disorientation

• Labile affect

• Short attention span

• Impaired judgment

• Distractibility

➤ Disturbed

Thought Processes Disruption in

cognitive operations

and activities

Immediate The client will:

• Be free of injury

• Demonstrate decreased

anxiety level

• Respond to reality-based

interactions

initiated by others

Stabilization The client will:

• Interact on reality-based

topics

• Sustain attention and

concentration

to complete tasks or activities

Community The client will:

• Verbalize recognition of

delusional

thoughts if they persist

• Be free from delusions or

demonstrate

the ability to function without

responding to persistent

delusional

thoughts

Nursing Interventions

Be sincere and honest when

communicating with the client.

Avoid vague or evasive remarks.

Be consistent in setting

expectations, enforcing rules,

and so forth.

Do not make promises that you

cannot keep.

Encourage the client to talk with

you, but do not pry or cross-

examine for information.

Rationale

Delusional clients are

extremely sensitive about

others and can recognize

insincerity. Evasive

comments or hesitation

reinforces mistrust or

delusions.

Clear, consistent limits

provide a secure structure

for the client.

Broken promises reinforce

the client’s mistrust of

others.

Probing increases the

client’s suspicion and

interferes with the

therapeutic relationship.