INursing care plan Assessment Objective: - Active - Agitated - Irritable -Seen bumping her head against the wall and kicking her bed. Nursing Diagnosis Violence: Self directed related to impaired sensory perception secondary to schizophrenia Planning Interventions Rationale Outcomes After 2days of nursing intervention the client will not harm to others as evidenced by: - good interpersonal relationship with copatients and staf - Patient demonstrate selfcontrol as evidenced by relaxed posture, nonviolent behavior. - Client will not harmself or others. Observed and maintained or listen to the client for early cues of distress and a calm attitude to client. For client safety. After 2days of nursing intervention the goal was met as evidenced by: Re-orient the client to person, place, and time. Repeated presentation of reality is concrete reinforcement for the client. Provide emotional support, positive reinforcement. Providing support and encouragement during the experience increases the patient’s sense of security and control. Positive reinforcement enhances selfesteem. Developed a therapeutic Presence, acceptance and - Maintained good interpersonal relationship with copatients and staf. - Patient demonstrate self-control as evidenced by relaxed posture nonviolent behavior. - Client will not harm self or others. nurse-client relationship through frequent, brief and an accepting attitude. Show unconditional positive regard. Encouraged to verbalize feelings. conveyance of positive regard enhance the client’s feeling of self worth. Verbalization of feelings in a nonthreatening environment may help client come to terms with long unresolved issues. Reestablish the client what is real and unreal. Validate client’s real perceptions, and correct the client’s misperception. Reality must be reinforced. Reinforced reality and behavior will recur more frequently. Assessed type of hallucination the patient experiencing. Encouraged patient to gradually discuss To rule out proper intervention for a specific Hallucination. So the client has the chance to seek others and experiences that occurred before the onset of hallucination. to cope problems caused by hallucination. Assessed for any suicidal ideation or violent behavior. Patient experiencing hallucination may tend to be violent. Maintained distance from client. Provided client with a sense that caregiver is in control of the situation. Administered prescribed medication. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Patient will be violent. To provide feeling of safety. To calm the client and may prevent aggressive behavior. RATIONALE EVALUATION SUBJECTIVE “Hi ate ako nurse, ikaw pasyente”; “lika ate laro tayo, akyat tayo sa taas” as verbalized. OBJECTIVE : - Not oriented to time, date - Olfactory hallucination noted as evidence of “Ayaw ko po kumain nung pagkain nila dito, iba po yung amoy, masarap po kasi yung pagkain naming dun sa amin”. - Circumstantialit y - Rapid shift of mood. - Short attention span. - Answers questions being asked inappropriately. Disturbed thought process related to mental disorder. ST : After 8 hours of therapeutic nursing intervention the patient will be responding to questions being asked appropriately. Approach in a calm manner. To established nursepatient relationship. Assess signs and symptoms of physical illness. To determine immediate and appropriate nursing intervention. Re- orient client to time, date, place, person. To bring back to reality. LT : After 2 days of therapeutic and holistic nursing intervention the patient will be able to eat foods being served at the institution and continuing compliance to medications. Encouraged to do activity of daily living independently. For the patient not to remember or feel the triggering factors and to maintain body functions. Interact with the client on a real basis. Interacting about reality in healthy. Encouraged verbalization of feelings and concerns. For appropriate and immediate nursing intervention. Supervised in giving oral medications. To ensure the patient swallowed medications being given. Seen from time to time. To ensure safety and for assessment of other signs and symptoms. ST : After 8 hours of continuous nursing intervention patient still doesn’t answers questions being asked appropriately. LT : After 2 days of nursing intervention patient still doesn’t want to eat foods being served from the institution because she said she could smell something diferent from the food.
Report "Nursing Care Plan for Paranoid Schizophrenia"