Nursing Care Plans Schiz

AssessmentNursing

Diagnosis

Scientific

explanationPlanning

Nursing

InterventionsRationale

Expected

Outcome

S: Ø

O: patient

manifested:

Patient may

manifest:

Restlessness

Panic

Delirium

Self mutilation

Risk for

injury: self

directed r/t

command

hallucinations

Schizophrenia is a mental illness in which patients experience symptoms such as delusions, (mistaken beliefs) hallucinations, and disorganized behavior. Hallucinations are sounds or other sensations experienced as real when they exist only in the person's mind. While hallucinations can involve any of the five senses, auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. Visual

Short Term:

After 4 hours of NI the patient will not harm himself

Long Term:

After 2 days of NI the patient will refrain from suicidal threats or behaviour gestures.

Observe patient’s behaviour during routine patient care.

Assess the congruency of behaviors

Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent.

Self esteem enhancement-self esteem journal, give positive feedback,

Hallucination management-assess, help client describe needs that might be reflected

Close observation is necessary to protect from self harm.

To determine the need for prompt intervention

Such behaviours are critical clues regarding risk for self harm.

To improved self esteem and avoid risk for suicidal ideations

To determine the need for prompt

Short Term:

After the NI the patient shall not have harmed himself

Long Term:

After the NI the patient shall have refrained from suicidal threats or behaviour gestures.

hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner self-talk as coming from an outside source. People with schizophrenia have a high risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with schizophrenia are especially likely to commit suicide during psychotic episodes, during periods of depression, and in the first six months after

in the content of the hallucination, identify triggers of hallucinations

Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .

intervention

Suicide risk increases when plans and means exists

they’ve started treatment thus confirming the diagnosis.

AssessmentNursing

Diagnosis

Scientific

explanationPlanning

Nursing

InterventionsRationale

Expected

Outcome

S: Ø

O: patient

manifested:

Auditory

and visual

hallucinati

ons

Misinterpr

ets actions

of others

Inability

to make

simple

decisions

Inappropri

ate

responses

Patient may

manifest:

Disturbed

sensory

perception

related to

alteration in

function of

brain tissue

Schizophrenia is a

mental illness in

which patients

experience

symptoms such as

delusions,

(mistaken beliefs)

hallucinations,

and disorganized

behavior. It is the

change in the

amount or

patterning of

incoming stimuli

accompanied by a

diminished,

exaggerated,

distorted, or

impaired response

to such stimuli.

Short Term:

After 2 hours of NI the pt will demonstrate accurate perception of the environment by responding appropriately to stimuli in the surroundings

Long Term:

After 2 days of

NI the pt has

lessened visual

and auditory

hallucinations

Continuously orient

the client to actual

environmental

events or activities

in a nonchallenging

way.

Reinforce and focus

on reality. Talk

about real events

and real people. Use

real situations and

events to divert

client from long,

tedious, repetitive

verbalizations of

false ideas

Correct client's

description of

Brief, frequent

orientation helps

to present reality

to the client with

sensory-

perception

disturbance

Working with reality lessens patient’s initiation of his hallucinations.

Explanation of, and participation in, real

Short Term:

Long Term:

Restlessness

Panic

Delirium

Self mutilation

inaccurate

perception, and

describe the

situation as it exists

in reality

Explore the content

of hallucinations to

determine the

possibility to harm

self, others or the

environment

situations and real activities interferes with the ability to respond to hallucinations.

Exploring the

content of the

hallucination

helps the nurse

identify if the

sensory-

perceptual

disturbance is

threatening or

dangerous to the

client, such as a

command type

of hallucination

that may be

telling the client

to harm or kill

Use clear, direct,

verbal

communication

rather than unclear

or nonverbal

gestures

the client or

others. The

nurse can then

reinforce

treatment and

safety

precautions.

Unclear directions or instructions can confuse the client and promote distorted perceptions or misinterpretations of reality.

TIME

AND

DATE

CUES NEED NURSING

DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

Januar

y 21,

2009

@

7:00

A.M

SUBJECTIVE

“Magpatambal ko. Kani

man gud akong utok, naa

niy grasa.” as verbalized

by the patient

OBJECTIVE

Delusion of

persecution

Delusion of

paranoia

Thought insertion

Incoherent speech

Demonstrates a

disturbance in

sleep pattern

Presence of

C

O

G

N

I

T

I

V

E

-

P

E

R

C

E

P

T

U

Disturbed

thought process

related to

disintegration

thinking.

®It is the

disruption in

cognitive

operations and

activities.

Cognitive

processes

include those

mental

processes by

which

knowledge is

At the end of 2

hours of nursing

care, the patient

will be able to

Maintain

reality

orientation;

Demonstrat

e reality

based

thinking in

verbal and

nonverbal

behavior;

and

Demonstrat

e the ability

to abstract,

1. Be sincere and

honest when

communicating

with the client.

®Clients are

extremely sensitive

about others and

can recognize

insincerity. Evasive

remarks reinforce

mistrust.

2. Assess client’s

nonverbal behavior,

such as gestures,

facial expression

and posture.

January 21, 2009

@ 12:30 PM

GOAL

PARTIALLY

MET

The client

was able to

maintain

reality

orientation.

He is

oriented to

time when

asked what

day it is.

But he is

still

auditory

hallucinations

A

L

P

A

T

T

E

R

N

acquired. These

mental

processes

include reality

orientation,

comprehension,

awareness, and

judgment. A

disruption in

these mental

processes may

lead to

inaccurate

interpretations

of the

environment

and may result

in an inability to

evaluate reality

accurately.

Alterations in

thought

processes are

conceptuali

ze, reason

and

calculate

consistent

with ability

to

®This assessment

may help to meet

the client’s needs

that cannot be

conveyed through

speech.

3. Encourage the

client to express

feelings and do not

pry cross examine

for information

®Probing increases

client’s suspicion

and interferes with

the therapeutic

relationship

4. Show empathy to

the client’s

feelings, reassure

preoccupied

with his

delusions

about his

being

jealous to

him

The client

was not able

to

demonstrate

reality-

based

thinking in

verbal and

nonverbal

responses.

His

mannerism

is largely

observed

and he

not limited to

any one age

group, gender,

or clinical

problem.

(http://

www1.us.elsevie

rhealth.com/

MERLIN/

Gulanick/

Constructor/

index.cfm?

plan=53.01)

the client of your

presence and

acceptance

®The client’s

experiences can be

distressing.

Empathy conveys

acceptance of the

client your caring

and interest.

5. Avoid laughing,

whispering, or

talking quietly

where client can

see but not hear

what is being said.

®Suspicious clients

often believe others

are discussing

them, and secretive

wasn’t able

to establish

eye contact

with any of

the

interviewer.

However,

he was able

to exhibit a

positive

abstract,

reason,

judgment

and

calculation

abilities.

behaviors reinforce

the paranoid

feelings.

6. Give simple

directions using

short words and

simple sentences.

® Giving simple

directions lessen or

prevent confusion

of the patient

7. Never convey to

the client that his

delusions and

hallucinations are

real

®The delusion or

hallucination would

be reinforce if it’s

accepted.

8. Maintain reality

oriented

relationship and

environment

® Maintaining

reality based

relationship and

environment lets

the patient know

that the relationship

is temporary and

prevents separation

anxiety

9. Give positive

feedbacks and

acknowledge the

client

®Positive feedback

enhances sense of

well-being and

makes a more

positive situation

for the client.

10. Do not judge or

belittle client’s

beliefs.

®What the client

feels or thinks is

not funny for him.

The client may feel

rejected if

approached by

attempts of humor.

TIME

AND

DATE

CUES NEED NURSING

DIAGNOSIS


.Janua

ry 21,

2010

@ 12

:30

PM

SUBJECTIVE:

“Maulaw man gyud ko

basta ing-ana”

OBJECTIVE:

Lacking eye

contact

Lack social

interaction

Has little interest

in activities

Talks only when

asked

S

E

L

F

-

P

E

R

C

E

P

T

I

O

N

Situational low

self-esteem

related to

cognitive

impairment

It is the state in

which an

individual who

previously had

positive self-

esteem

experience a

negative feeling

towards self due

to a certain

situation

At the end of 2

hours of nursing

care, the patient

will:

Verbalize

understandi

ng of things

that

precipitate

current

situation;

and

Demonstrat

e behaviors

that show

positive

self-esteem

1. Encourage client to

express honest

feelings in relation

to loss of prior level

of functioning.

Acknowledge pain

of loss. Support

client through

process of grieving.

® Client may be

fixed in anger stage

of grieving process,

which is turned

inward on the self,

resulting in

diminished self-

esteem.

January 21, 2010

@ 2:30 PM

GOAL UNMET

The patient

was unable to

verbalize

understanding

of things that

lead to current

situation

The patient

was unable to

demonstrate

behaviors that

show positive

self-esteem as

Handbook of

Nursing

Diagnosis by

Lynda Juall

Carpenito-

Muyet

2. Devise methods for

assisting client to

express feelings

properly..

® To explore the

feelings of the

client thereby

allowing him to

acknowledge his

own strength and

weakness.

3. Encourage client's

attempts to

communicate. If

verbalizations are

not understandable,

express to client

what you think he

or she intended to

say. It may be

necessary to

evidenced by

inability to have

an eye-contact

as well as

looking down at

during the

interview.

reorient client

frequently.

® The ability to

communicate

effectively with

others may enhance

self-esteem.

4. Encourage

reminiscence and

discussion of life

review. Also

discuss present-day

events. Sharing

picture albums, if

possible, is

especially good. ®

Reminiscence and

life review help the

client resume

progression through

the grief process

associated with

disappointing life

events and increase

self-esteem as

successes are

reviewed.

5. Encourage

participation in

group activities.

Caregiver may need

to accompany client

at first, until he or

she feels secure that

the group members

will be accepting,

regardless of

limitations in verbal

communication.

® Positive

feedback from

group members will

increase self-

esteem.

6. Offer support and

empathy when

client expresses

embarrassment at

inability to

remember people,

events, and places.

® Focus on

accomplishments to

lift self-esteem.


be as independent

as possible in self-

care activities.

® The ability to

perform

independently

preserves self-

esteem.

8. Listen to patient’s

concerns and

verbalizations

without comment

or judgment.

®It enables the

client to develop

trust and thereby

establish

communication

9. Provide feedback to

client’s negative

feelings.

®To allow the

client experience a

different view.

TIME

AND

DATE

CUES NEED NURSING

DIAGNOSIS


January

21,

2010

@12:30

PM

SUBJECTIVE:

The clarified when

exactly was the 2

months he was referring

about his last used of

marijuana, he verbalized

“Kadtong 2007 man to,

aw 2008 diay”

OBHECTIVE:

Disorientation to

time

Observed

experience of

forgetting

Scratches his

head when he is

C

O

G

N

I

T

I

V

E

-

P

E

R

C

E

P

T

Impaired

memory related

to neurological

disturbances

®Impaired

memory is

directly related

to effects of

general medical

condition or

ongoing effects

of substance.

Depending o n

the areas of the

brain, the client

are unable to

recall

At the end of 3 day

nursing care, the

patient will be able

to:

Verbalize

awareness

of memory

problems;

and

Accept

limitations

of current

condition

1. Provide

opportunities for

reminiscence or

recall past events

®Long-term

memory may

persist after loss of

recent memory.

Reminiscence is

usually an

enjoyable activity

for the client.

2. Encourage the

client to use written

cues such as

calendars or

January 21, 2010

@ 2:30 PM

GOAL MET

The patient

was able to

verbalize

awareness

of memory

problems

as he

verbalized

“Usahay

gyud

makalimot

na ko”

The patient

unable to recall

information

Inability to

determine if a

behavior is

performe

U

A

L

information,

either remote or

recent. The

client may

confabulate to

fill in those lost

memories.

notebooks

®Written cues

decrease the

client’s need to

recall activities,

plans and so on

from memory.

3. Encourage

ventilation of

feelings of

frustration,

helplessness, and so

forth. Refocus

attention to areas of

focus and progress.

®To lessen feelings

of

powerlessness/hope

lessness

4. Provide for proper

pacing of activities

and having

appropriate rest

was able to

verbalize

acceptance

of his

limitations

due to his

conditions

®To avoid fatigue

5. Allow the client to

do tasks on his

own, but do not

rush him to do it.

Make the client feel

that he can still do

things

independently.

®It is important to

maximize

independent

function, assist the

client when

memory has

deteriorated further.

6. Assist the client

deal with functional

limitations and

identify resources.

®To meet

individual needs,

maximizing

independence.

7. Provide single step

instructions when

instructions are

needed.

®Client with

memory

impairment cannot

remember multistep

instructions

8. Do not contradict

the client who

experiences an

illusion. Instead,

simply explain

reality, and find

some practical

solutions to the

problem

®Therapeutic

responses promote

reality while

offering solutions

that help enhances

the client’s sense

and may reduce

fear, anxiety, and

confusion.

9. Monitor client’s

behavior and assist

in use of stress-

management

techniques

®To reduce

frustration

10. Determine client’s

response to

medication

medications

prescribe to

improve attention,

concentration,

memory process

and to lift spirits

and modify

emotional

responses.

®Helpful in

deciding whether

quality of life is

improved when

using the

medications

prescribed.

TIME

AND

DATE

CUES NEED NURSING

DIAGNOSIS


January

21,

2010 @

12:30

P.M.

SUBJECTIVE:“Makatamad usahay maligo. Wala pa gani ko ligo ron. Kapoy pud manlimpyo ug kuko”, as verbalized by the patient.

OBJECTIVE:Unkempt hair notedfood stains visible on clothinguntrimmed fingernails and toenails with visible dirt noted

A

C

T

I

V

I

T

Y

-

E

X

E

Self care deficit:

bathing /

hygiene related

to lack of

motivation

® The patient

has an impaired

ability to

provide self care

requisites due to

environmental

and

After 2 hours of nursing care, the client will be able to:

a) verbalize

self care

need

b) Demonstrat

e

techniques

to meet

self-care

needs

1. Establish rapport.

R: to gain client’s trust and facilitate a good working relationship.

2. Identify reason for

difficulty in self-

care.

R: underlying cause affects choice of interventions/ strategies.

3. Determine hygienic

January 21, 2009

@ 2:30 PM

GOAL

PARTIALLY

MET

After 2 hours of

nursing care, the

client was able to:

a) verbalize

self care

R

C

I

S

E

P

A

T

T

E

R

N

psychological

factors.

needs and provide

assistance as

needed with

activities like care

of nails and

brushing teeth.

R: basic hygienic needs may be forgotten.

4. Discuss on

importance of

hygiene.

R: makes client aware of how hygiene is vital in caring for oneself.

5. Orient client to

different equipment

for self-care like

various toiletries.

R: increases the client’s awareness of different materials for self-care.

6. Let the patient

enumerate his ideas

need

b) but was

unable to

demonstrate

techniques

to meet self-

care needs.

on the importance

of hygiene.

R: Encourages the patient to understand the need for hygiene.

7. Discuss the

possible negative

implications of not

taking a bath such

as infections and

odor.

R: Broadens the

patient’s idea about

the problem and

encourages him to

meet the need.


perform self-care to

the maximum of

ability as defined

by the client. Do

not rush client.

R: promotes independence and

sense of control, may decrease feelings of helplessness.

9. Allot plenty of time

to perform tasks.

R: cognitive impairment may interfere with ability to manage even simple activities.

10. Assist with

dressing neatly or

provide colorful

clothes.

R: Enhances esteem and convey aliveness.

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