Assessment
S: Ø
O: patient manifested:
Patient may manifest: Restlessness Panic Delirium Self mutilation
Nursing
Scientific
Diagnosis
explanation
Risk for
Planning
Nursing Interventions
Schizophrenia is a Short Term: Observe patient¶s mental illness in behaviour during injury: self which patients routine patient After 4 hours directed r/t experience care. of NI the symptoms such as command patient will not delusions, harm himself hallucinations (mistaken beliefs) hallucinations, Assess the and disorganized congruency of behavior. behaviors Long Term: Hallucinations are sounds or other Listen carefully sensations After 2 days of suicidal statements experienced as NI the patient and observe for real when they will refrain non-verbal exist only in the from suicidal indications of person's mind. suicidal intent. threats or While behaviour hallucinations can gestures. Self esteem involve any of the enhancement-self five senses, esteem journal, auditory give positive hallucinations feedback, (e.g. hearing voices or some Hallucination other sound) are managementmost common in assess, help client schizophrenia. describe needs that Visual might be reflected
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
To determine the need for prompt
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.
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 depression, and in the first six months after
in the content of the hallucination, identify triggers of hallucinations
intervention
Ask direct questions to Suicide risk determine suicidal increases when intent , plans for plans and suicide, and means means exists to commit suicide .
of
they¶ve started treatment thus confirming the diagnosis.
Assessment
Nursing
Scientific
Diagnosis
explanation
Disturbed
Schizophrenia is a
sensory
O: patient
perception
manifested:
related to
S: Ø
y
Auditory
alteration in
and visual function of hallucinati brain tissue ons y
y
y
Misinterpr
Planning
Interventions
Brief,
mental illness in
the client to actual
orientation helps
After 2 hours which patients of NI the pt experience will demonstrate symptoms such as accurate perception of delusions, the environment (mistaken beliefs) by responding appropriately to hallucinations, stimuli in the and disorganized surroundings
environmental
to present reality
events or activities
to the client with
in a nonchallenging
sensory-
way.
perception
behavior. It is the
of others
change in the
Inability
amount or
After 2 days of
to
patterning of
NI the pt has
simple
incoming stimuli
decisions
accompanied by a
Inappropri
diminished,
ate
exaggerated,
responses
distorted, or impaired response
Patient may
Rationale
Continuously orient
Short Term:
ets actions
make
Nursing
to such stimuli.
Long Term:
lessened visual and auditory hallucinations
frequent
disturbance Working with reality lessens patient¶s on reality. Talk initiation of his about real events hallucinations. and real people. Use Reinforce and focus
real situations and events
to
divert
client
from
long,
tedious,
repetitive
verbalizations
of
false ideas Correct description
Explanation of, and participation of in, real situations and
client's
Expected Outcome
Short Term: Long Term:
inaccurate
Delirium
real activities interferes with perception, and the ability to describe the respond to hallucinations. situation as it exists
Self mutilation
in reality
manifest: Restlessness Panic
Explore the content of hallucinations to determine
the
possibility to harm self, others or the environment
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 the
client
others.
or The
nurse can then reinforce treatment
and
safety precautions.
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.
TIME
CUES
NEED
AND
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE Januar SUBJECTIVE
C
Disturbed
At the end of 2
y 21,
³Magpatambal ko. Kani
O
thought process
hours of nursing
honest
2009
man gud akong utok, naa
G
related to
care, the patient
communicating
@
niy grasa.´ as verbalized
N
disintegration
will be able to
with the client.
7:00
by the patient
I
thinking.
A.M
y
T
OBJECTIVE y
Delusion
and when
January 21, 2009 @ 12:30 PM
GOAL PARTIALLY
Maintain
®Clients
orientation;
extremely sensitive
Demonstrat
about
cognitive
e
can
operations and
based
insincerity. Evasive
reality orientation.
®It is the
V
disruption in
-
persecution
sincere
reality
I
of E
1. Be
y
reality
are
others
and
recognize
y
The
client
was able to maintain
Delusion
of P
activities.
thinking in
remarks
paranoia
E
Cognitive
verbal and
mistrust.
y
Thought insertion
R
processes
nonverbal
y
Incoherent speech
C
include those
behavior;
y
Demonstrates
a
E
mental
and
nonverbal behavior,
asked what
in
P
processes by
Demonstrat
such as gestures,
day
it
is.
T
which
e the ability
facial
But
he
is
knowledge is
to abstract,
and posture.
acquired. These
conceptuali
mental
ze,
y
disturbance sleep pattern y
Presence auditory hallucinations
of U A L
y
reason
reinforce
MET
He
is
oriented to 2. Assess
client¶s
expression
time
when
still preoccupied
®This
assessment
with
his
processes
and
may help to meet
delusions
P
include reality
calculate
the client¶s needs
about
A
orientation,
consistent
that
being
T
comprehension,
with ability
conveyed
T
awareness, and
to
speech.
E
judgment. A
R
disruption in
3. Encourage
N
these mental
client
processes may
feelings and do not
to
lead to
pry cross examine
demonstrate
inaccurate
for information
reality-
cannot
be
through
his
jealous
to
him
the
to
y
express
The
client
was not able
interpretations
based
of the
®Probing increases
thinking
environment
client¶s
verbal
and may result
and interferes with
nonverbal
in an inability to
the
responses.
evaluate reality
relationship
suspicion
therapeutic
and
His
accurately. Alterations in
in
mannerism 4. Show empathy to
thought
the
processes are
feelings,
not limited to
the client of your
any one age
is
client¶s
observed
reassure
presence
largely
and
he
wasn¶t able and
to establish
group, gender,
acceptance
eye contact
or clinical
with any of
problem.
®The
client¶s
the
(http://www1.us.
experiences can be
elsevierhealth.c
distressing.
om/MERLIN/Gu
Empathy
conveys
he was able
lanick/Construct
acceptance of the
to exhibit a
or/index.cfm?pl
client your caring
positive
an=53.01)
and interest.
abstract,
interviewer. y
However,
reason, 5. Avoid
laughing,
whispering, talking where
or quietly
client
can
see but not hear what is being said.
®Suspicious clients often believe others are
discussing
them, and secretive behaviors reinforce the
paranoid
judgment and calculation abilities.
feelings.
6. Give
simple
directions short
using
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
positive
more 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 approached
if by
attempts of humor.
TIME
CUES
NEED
AND
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE .Janua
SUBJECTIVE:
S
Situational low
At the end of 2
ry 21,
³Maulaw man gyud ko
E
self-esteem
hours
of
nursing
express
2010
basta ing-ana´
L
related to
care,
the
patient
feelings in relation
F
cognitive
will:
-
impairment
@ 12 :30 PM
OBJECTIVE: y
Lacking
eye
y
Verbalize
Acknowledge pain
understandi
of
R
which an
ng of things
client
interaction
C
individual who
that
process of grieving.
Has little interest
E
previously had
precipitate
Lack
social
P
Talks only when
T
asked
I O N
positive self-
current
esteem
situation;
experience a negative feeling towards self due to a certain situation
y
Demonstrat e behaviors that
show
positive self-esteem
H andbook
Nursing
of
loss.
@ 2:30 PM
GOAL UNMET
y
The patient
Support
was unable to
through
verbalize understanding of things that
® Client may be fixed in anger stage of grieving process,
and
January 21, 2010
functioning.
It is the state in
in activities y
to loss of prior level of
y
honest
E
contact y
P
1. Encourage client to
which is turned inward on the self, resulting in diminished selfesteem. 2. Devise methods for assisting client to
lead to current situation y
The patient
was unable to demonstrate behaviors show
that
positive
self-esteem
as
evidenced
by
inability to have
Diagnosis
by
Lynda Juall
express
feelings
properly..
as
Carpenito Muyet
an
eye-contact well
as
looking down at ® To explore the feelings of the
interview.
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
necessary reorient frequently.
during
be to
client
the
® 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,
especially good. ® Reminiscence
and
life review help the client
resume
progression through the
grief
process
associated
with
disappointing
life
events and increase
is
self-esteem
as
successes
are
reviewed. 5. Encourage
participation
group
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
embarrassment
at
inability
to
remember
people,
events, and places. ®
Focus
on
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 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
CUES
NEED
AND
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
1. Provide
January 21, 2010
DIAGNOSIS
DATE January
SUBJECTIVE:
C
Impaired
At the end of 3 day
21,
The clarified when
O
memory related
nursing care, the
opportunities
2010
exactly was the 2
G
to neurological
patient will be able
reminiscence
@12:30
months he was referring
N
disturbances
to:
recall past events
PM
about his last used of
I
®Impaired
marijuana, he verbalized
T
³Kadtong 2007 man to, aw 2008 diay´
y
memory is
awareness
memory
I
directly related
of memory
persist after loss of
verbalize
V
to effects of
problems;
recent
awareness
E
general medical
and
Reminiscence
-
condition or
Accept
usually
Disorientation to
P
ongoing effects
limitations
enjoyable
time
E
of substance.
of
for the client.
Observed
R
Depending o n
condition
of C
the areas of the
E
brain, the client
client to use written
makalimot
his
P
are unable to
cues
na ko´
head when he is
T
recall
calendars
unable to recall
U
information,
notebooks
information
A
either remote or
®Written
L
recent. The
decrease
forgetting
y
GOAL MET
®Long-term
experience
y
or
Verbalize
OBHECTIVE: y
for @ 2:30 PM
Scratches
Inability
to
y
y
current
y
may
The patient was able to
memory. is
of memory
an
problems
activity
as
he
verbalized ³Usahay
2. Encourage
such
the
gyud
as or
y
The patient was able to
cues the
verbalize acceptance
determine
if
behavior
performe
a is
client may
client¶s
need
to
confabulate to
recall
activities,
fill in those lost
plans and so on
due to his
memories.
from memory.
conditions
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 ®To avoid fatigue 5. Allow the client to do
tasks
on
his
of
his
limitations
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 individual
meet 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 stressmanagement techniques ®To
reduce
frustration 10. Determine client¶s response
to
medication medications
prescribe
improve
to
attention,
concentration, memory
process
and to lift spirits and
modify
emotional responses. ®Helpful deciding
in whether
quality of life is improved
when
using
the
medications prescribed. TIME
CUES
NEED
AND
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
After 2 hours of nursing care, the client will be able to: a) verbalize
1. Establish rapport.
January 21, 2009
R: to gain client¶s trust and facilitate a good working relationship.
@ 2:30 PM
DIAGNOSIS
DATE January 21, 2010 @ 12:30 P.M.
SUBJECTIVE: ³Makatamad 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
Self care deficit:
C
bathing /
T
hygiene related
I
to lack of
V
motivation
I
® The patient
T
has an impaired
Y
ability to
E X
provide self care requisites due to environmental
self
care
b) Demonstrat
techniques meet
self-care needs
After 2 hours of
R: underlying cause affects choice of interventions/ strategies.
nursing care, the client was able to: a) verbalize
E
and
R
psychological
needs and provide
C
factors.
assistance
I
MET
difficulty in selfcare.
e
to
PARTIALLY 2. Identify reason for
need
GOAL
3. Determine hygienic
needed
as with
self
care
need b)
but
unable
was to
S
activities like care
demonstrate
E
of
techniques
nails
and
brushing teeth. P
to meet self-
A
R: basic hygienic needs may be forgotten.
T
4. Discuss
on
T
importance
E
hygiene.
R N
of
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 on the importance of hygiene. R: Encourages the
care needs.
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. 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
colorful
clothes. R: Enhances esteem and convey aliveness.
