Nursing Care Plans Schiz
Nursing Care Plans Schiz
Nursing Care Plans Schiz
Scientific explanation 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
Planning Short Term: After 4 hours of NI the patient will not harm himself
Rationale 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
Expected Outcome 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.
O: patient manifested:
Long Term: After 2 days of NI the patient will refrain from suicidal threats or behaviour gestures.
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 managementassess, help client describe needs that might be reflected
hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner selftalk 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
intervention
Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .
Assessment S:
Nursing Diagnosis
Disturbed sensory
Scientific explanation
Planning
Nursing Interventions
Rationale
Expected Outcome
Schizophrenia is a Short Term: 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
O: patient manifested:
y Auditory
and visual function of hallucinati brain tissue ons y Misinterpr ets actions of others y Inability to make
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
environmental
events or activities to the client with in a nonchallenging sensoryway. perception disturbance Working with Reinforce and focus reality lessens on reality. Talk patients initiation of his about real events hallucinations. and real people. Use real situations and events client tedious, to from divert long,
repetitive of
Patient may
to such stimuli.
client's Explanation of, and participation description of in, real situations and Correct
inaccurate
real activities interferes with perception, and the ability to describe the respond to hallucinations. situation as it exists in reality the Explore the content Exploring of hallucinations to content of the the hallucination helps the nurse possibility to harm self, others or the identify if the determine environment sensoryperceptual disturbance threatening is or
others.
Use clear, direct, Unclear directions or verbal instructions can communication confuse the rather than unclear client and promote or nonverbal distorted perceptions or gestures misinterpretatio ns of reality.
CUES
NEED
NURSING DIAGNOSIS
GOAL OF CARE
INTERVENTIONS
EVALUATION
SUBJECTIVE Magpatambal ko. Kani man gud akong utok, naa niy grasa. as verbalized by the patient
C O G N I T I
At the end of 2 hours of nursing care, the patient will be able to y Maintain reality
1. Be
sincere
honest
communicating with the client. GOAL PARTIALLY Clients are MET y The client
It is the disruption in cognitive operations and activities. Cognitive processes include those mental processes by which knowledge is acquired. These mental y y
OBJECTIVE y Delusion persecution y Delusion paranoia y y y Thought insertion Incoherent speech Demonstrates disturbance sleep pattern y Presence auditory hallucinations
V of E of P E R C
based thinking in verbal and nonverbal behavior; and Demonstrat e the ability to abstract, conceptuali ze, reason
oriented to 2. Assess clients time when nonverbal behavior, such as gestures, facial expression
a E in P T of U A L
and posture.
This
assessment
with
his
processes P A T T E R N 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 not limited to any one age
conveyed speech.
through
3. Encourage client to
the express
The
client
relationship
is
largely
observed and he
group, gender, or clinical problem. (http://www1.us. elsevierhealth.c om/MERLIN/Gu lanick/Construct or/index.cfm?pl an=53.01)
acceptance
The
clients
5. Avoid
laughing, or quietly
whispering, talking
where client can see but not hear what is being said.
feelings.
words
simple sentences.
of the patient
7. Never convey to the client that his delusions hallucinations real and are
reality
and
reality
relationship environment
the patient know that the relationship is temporary and prevents separation anxiety
9. Give feedbacks
acknowledge client
makes positive
more situation
What the client feels or thinks is not funny for him. The client may feel rejected approached if by
attempts of humor.
CUES
NEED
NURSING DIAGNOSIS
GOAL OF CARE
INTERVENTIONS
EVALUATION
S E L F
feelings in relation to loss of prior level of functioning. y The patient GOAL UNMET
eye P E social R C
y It is the state in which an individual who previously had positive selfesteem experience a negative feeling towards self due to a certain situation y
Verbalize understandi ng of things that precipitate current situation; and Demonstrat e behaviors that show
client
process of grieving. Client may be fixed in anger stage of grieving process, which is turned inward on the self, resulting in diminished selfesteem. 2. Devise methods for assisting client to
positive self-esteem
positive as by
self-esteem evidenced
Handbook of Nursing
inability to have
express properly..
feelings
an eye-contact as well as
looking down at To explore the feelings of the client thereby allowing him to acknowledge his own strength and weakness. 3. Encourage client's attempts communicate. verbalizations to If are during interview. the
The ability to communicate effectively with others may enhance self-esteem. 4. Encourage reminiscence and
especially good. Reminiscence and life review help the client resume
as are
in
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 selfesteem. 6. Offer support and empathy when
client
expresses at to people,
accomplishments to lift self-esteem. 7. Encourage client to be as independent as possible in selfcare activities. The ability to perform independently preserves selfesteem. 8. Listen to patients concerns verbalizations without comment and
or judgment. It enables the client to develop trust and thereby establish communication 9. Provide feedback to clients feelings. To allow the client experience a different view. negative
CUES
NEED
NURSING DIAGNOSIS
GOAL OF CARE
INTERVENTIONS
EVALUATION
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
C O G N I T I V E
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 information, either remote or recent. The
At the end of 3 day nursing care, the patient will be able to: y Verbalize awareness of memory problems; and y Accept limitations of current
January 21, 2010 for @ 2:30 PM or GOAL MET y The patient was able to verbalize awareness of memory problems as he
OBHECTIVE: y
Disorientation to P time E R of C E
cues the
verbalize acceptance
Inability
clients recall
need
to
of
his
activities,
plans and so on from memory. 3. Encourage ventilation feelings frustration, helplessness, and so forth. Refocus of of
attention to areas of focus and progress. To lessen feelings of powerlessness/hope lessness 4. Provide for proper pacing of activities and having
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 memory when has
identify resources. To individual maximizing independence. 7. Provide single step instructions when meet needs,
are
with
impairment cannot remember multistep instructions 8. Do not contradict the client who an Instead, explain and find
practical to the
behavior and assist in use of stressmanagement techniques To frustration 10. Determine clients response medication medications prescribe to to reduce
and to lift spirits and emotional responses. Helpful deciding in whether modify
quality of life is improved using medications prescribed. TIME AND DATE 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 noted food stains visible on clothing untrimmed fingernails and toenails with visible dirt noted A C T I V I T Y E X E R C I 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 psychological factors. After 2 hours of nursing care, the client will be able to: a) verbalize self need b) Demonstrat e techniques to meet care 1. Establish rapport. R: to gain clients trust and facilitate a good working relationship. 2. Identify reason for difficulty in selfcare. R: underlying cause affects choice of interventions/ strategies. 3. Determine hygienic needs and provide assistance needed as with After 2 hours of nursing care, the client was able to: a) verbalize self need b) but unable was to care January 21, 2009 @ 2:30 PM CUES NEED NURSING DIAGNOSIS GOAL OF CARE INTERVENTIONS EVALUATION when the
self-care needs
S E
brushing teeth. P A T T E R N R: basic hygienic needs may be forgotten. 4. Discuss importance hygiene. R: makes client aware of how hygiene is vital in caring for oneself. 5. Orient client to on of
different equipment for self-care like various toiletries. R: increases the clients awareness of different materials for self-care. 6. Let the patient enumerate his ideas 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
encourages him to meet the need. 8. Encourage client to 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 clothes. R: Enhances esteem and convey aliveness. colorful