NURSING CARE PLAN 1

NURSING ASSESSMENT NURSING DIAGNOSIS NURSING GOAL NURSING RATIONALE EVALUATION

INTERVENTION

Subjective: Disturbed thought Short Term Independent: Short Term

-Patient verbalized he felt processes Within 8 hours of nursing 1. Maintain a pleasant 1. Patient may At the end of 8 hours of
unsafe and thought people interventions, the patient and quiet respond with nursing interventions, the
wanted to harm him will be able to: environment aggressive behavior patient was able to:
-Patient verbalized hearing 1. Verbalize if stimulated 1. Recognize
voices and engaged in recognition of 2. Provide safety 2. To prevent patient delusional thoughts
thirds person delusional thought. measures from harming through
conversations involving 2. Express logical and himself and others verbalization
both a man and woman reality based ideas 3. Present reality 3. Patient is extremely 2. Determine usual
-Patient verbalized he concisely and briefly sensitive and can reality orientation as
heard people talking about Long Term recognize insincerity demonstrated by
him and insulting him Within 2 days of nursing 4. Identify feelings 4. When patient feels asking the student
interventions, the patient related to delusion understood anxiety nurse to reorient
Objective: will be able to: may lessen himself every time
-Patient exhibited 1. Maintain usual 5. Interact with clients he experiences
apprehensive behavior, reality orientation and try to distract 5. The client is free of delusions
fatuous laughter, and 2. Determine him from his delusional thinking
hesitancy reality-based delusions by when focused on Long Term
-Patient exhibited thinking in verbal engaging in reality-based At the end of 2 days of
depressed mood and and non-verbal reality-based activities. nursing intervention, the
constricted affect behavior activities patient was able to:
-Patient exhibited paranoid 3. Be free from 1. Maintain usual
delusions and delusions of delusions or 6. Do not argue with reality orientation
reference. demonstrate the the client’s beliefs or 6. This only increases 2. Determine
-Patient exhibited poor ability to function try to convince that the client's reality-based
insight without responding the delusions are defensive position, thinking in verbal
to persistent false and unreal. thereby reinforcing and non-verbal
delusional thoughts false beliefs. behavior
7. Encourage healthy 3. Be free from
habits to optimize 7. All are vital to help delusions or
functioning such as keep the client in demonstrate the
maintaining remission. ability to function
medication regimen, without responding
 regular sleep to persistent
pattern, and delusional thoughts
self-care
Dependent:
1. Assist in identifying 1. To formulate
ongoing treatment procedures needed
needs for his well being

2. Administer 2. To help keep the

medications as client in remission
prescribed
 NURSING CARE PLAN 2
CUES NURSING DIAGNOSIS NURSING GOAL NURSING RATIONALE EVALUATION
INTERVENTIONS

SUBJECTIVE: Disturbed Sensory Short term: 1. Be alert for signs of 1. Might herald Short term:
● Patient verbalized Perception: Auditory At the end of 8 hours, increasing fear, hallucinatory At the end of 8 hours,
hearing voices for patient will be able to: anxiety, or agitation. activity. patient was able to:
the past 10 months 1. Demonstrate 1. Demonstrate
● Patient verbalized techniques that help 2. Provide unit techniques that help
that he felt unsafe distract him or her protocols for 2. Provide patient distract him or her
and thought that from the voices. suicidal/threats of safety. from the voices.
people wanted to 2. Learn ways to violence if the 2. Learn ways to
harm him refrain from patient plans to act refrain from
● Patient complained responding to on commands. responding to
of hearing voices hallucinations. hallucinations.
and engaged in third 3. State three 3. Decrease 3. State three
person symptoms they environmental 3. Decrease the symptoms they
conversations recognize when stimuli when potential for anxiety recognize when
involving both a their stress levels possible such as that might trigger their stress levels
man and woman; are high. minimal activity and hallucinations. are high.
heard people talking reduce noise.
about him and Long term: Long term:
insulting him, some At the end of 24 hours, 4. Avoid arguing about At the end of 24 hours,
of whom he knew patient will be able to: the patient’s 4. Attempting to patient was able to:
1. State that the voices delusional system. disprove the 1. State that the voices
OBJECTIVE: are no longer delusions is not are no longer
● Patient exhibited threatening, nor do helpful and will threatening, nor do
apprehensive they interfere with create mistrust. they interfere with
behaviour, fatuous his or her life. 5. Observe behaviour his or her life.
laughter, and 2. State, using a scale that suggests that 5. Help in identifying 2. State, using a scale
hesitancy from 1 to 10, that hallucination is situations and times from 1 to 10, that
● Seen suspicious “the voices” are less occurring. that might be most “the voices” are less
and felt uneasy with frequent. threatening to the frequent.
others 3. Maintain social patient. 3. Maintain social
● Revealed paranoid relationships. relationships.
delusions and
auditory
 hallucinations
● Had a premorbid
personality of being
introvert
● Mood was
depressed and
affect constricted
 NURSING CARE PLAN 3
CUES NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION
INTERVENTIONS
SUBJECTIVE: Anxiety Short Term: INDEPENDENT: Short Term:
● Patient verbalized At the end of 8 hours of 1. Accept a patient's 1. If defenses are not At the end of 8 hours of
hearing voices for nursing interventions the defenses; do not threatened, the nursing interventions, the
the past 10 months patient will be able to: dare, argue, or patient may feel patient was able to:
and he felt unsafe 1. Express anxiety debate. secure and 1. Express anxiety
and thought that level and pattern. protected enough to level and pattern.
people wanted to 2. Demonstrate look at behavior. 2. Demonstrate
harm him personal coping 2. Converse using a 2. When experiencing personal coping
● Patient felt uneasy mechanisms for simple language moderate to severe mechanisms for
with other people anxiety attacks. and brief anxiety, patients anxiety attacks.
● Patient complained 3. Verbalize decrease statements. may be unable to 3. Verbalize decrease
of difficulty sleeping in anxiety levels. understand anything in anxiety levels.
● Patient reported 4. Demonstrate more than simple, 4. Demonstrate
loss of appetite increased clear, and brief increased
physiologic and instruction. physiologic and
psychological 3. Lessen sensory 3. Anxiety may psychological
OBJECTIVE: comfort. By not stimuli by keeping a intensify to a panic comfort. By not
● Patient appeared pacing to and fro the quiet and peaceful state with excessive pacing to and fro the
emaciated ward. environment; keep conversation, noise, ward.
● Patient showed “threatening” and equipment
apprehensive Long Term: equipment out of around the patient. Long Term:
behaviour and At the end of 24 hours of sight. increasing anxiety At the end of 24 hours of
hesitancy nursing interventions may become nursing interventions, the
● Patient paced to patient will be able to: frightening to the patient was able to:
and fro in the ward 1. Verbalize lessened patient and others. 1. Verbalize lessened
● Patient verbalized feelings of threat 4. Allow the patient to 4. Talking about feelings of threat
fear due to the and anxiety around talk about anxious anxiety-producing and anxiety around
death threats he has other people. feelings and situations and other people.
been receiving in his 2. Perform self care examine anxious feelings can 2. Perform self care
phone like eating nutritious anxiety-provoking help the patient like eating nutritious
meals on time, situations if they are perceive the meals on time,
dressing identifiable. situation realistically dressing
appropriately, and and recognize appropriately, and
maintaining factors leading to maintaining
hygiene. the anxious feelings. hygiene.
3. Express better sleep 5. Assist the patient in 5. Discovering new 3. Express better sleep
comfort, pattern, developing new coping methods comfort, pattern,
 and duration. anxiety-reducing provides the patient and duration.
4. Demonstrate skills (e.g., with a variety of 4. Demonstrate
calming techniques relaxation, deep ways to manage calming techniques
as taught by breathing, positive anxiety. as taught by
healthcare visualization, and healthcare
providers. reassuring providers.
self-statements)
6. Educate the patient 6. If the patient and
and family about the family can identify
symptoms of anxious responses,
anxiety. they can intervene
earlier than
otherwise.